The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Participates in individual and group therapy.

Demonstrates effective ways to cope with anxiety.

Takes all antianxiety medications as prescribed.

Learns methods of relaxation to reduce anxiety.

Answer and Explanation

The Correct Answer is B

A.   Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B.   Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D.   Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

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Correct Answer is C

Explanation

A. Alprazolam is a benzodiazepine used for anxiety and should not necessarily be discontinued solely based on discontinuation of an antipsychotic.
B. Lithium is a mood stabilizer commonly used in bipolar disorder but is not necessarily discontinued with the discontinuation of an antipsychotic.
C. Benztropine is an anticholinergic medication often used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications. If the antipsychotic is discontinued,
benztropine may also be discontinued.
D. Magnesium is not typically associated with antipsychotic use, and its discontinuation would depend on the specific indication and circumstances.

A. Explain to the client that her behavior invades the rights of the nursing staff. B. Teach the client strategies to control her obsessive-compulsive behavior. C. Ask the client to explain why she is keeping a detailed record of her nursing care. D. Encourage the client to express her feelings regarding the upcoming procedure. E. None F. None

Correct Answer is D

Explanation

A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.

B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.

C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.

D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.

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The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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