Psych CH14
A client with generalized anxiety disorder states that the client is worried about the client's job. The client never feels like the client has control over the client's responsibilities, even though the client puts in extra hours. The client adds that the client is afraid the client will be fired. Which response by the nurse is most therapeutic? "Has something changed at work that is causing you to worry?" "Why do you think you'll be fired?" "Your worries are a feature of your anxiety disorder. Tell yourself that you have nothing to worry about." "It sounds to me like you're doing a good job."
"Has something changed at work that is causing you to worry?" The nurse begins an assessment by simply asking the client if he or she is currently feeling anxious or worried or has experienced these feelings recently. The nurse also asks the client about obsessive thinking patterns, worrying, compulsions and repetitive activity, specific phobias, and exposure to traumatic events. Once the nurse has determined that signs and symptoms of anxiety do exist, the nurse assesses the possible underlying causes and inquires about family history, recent life events, current stress level, personal history of anxiety, medical and medication history, history of substance abuse, and other possible causes of the anxiety.
A nurse is giving a presentation on mental health promotion to college students. One student asks the nurse to explain the difference between normal anxiety and an anxiety disorder. Which response is best? "Normal anxiety does not result in feelings of dread or restlessness." "People with anxiety disorders experience a fight-or-flight response when threatened." "Normal anxiety occurs in response to everyday stressors." "People with anxiety disorders generally find that the anxiety interferes with daily activities."
"People with anxiety disorders generally find that the anxiety interferes with daily activities." Pathologic anxiety is suspected if a person feels anxious when no real threat exists, when a threat has passed long ago but continues to impair the person's functioning, or when a person substitutes adaptive coping mechanisms with maladaptive ones.
Which statement by the nurse demonstrates an understanding of the role automatisms have in a panic attack? "I discourage her finger tapping since it serves to increase her anxiety level." "I can tell that the more she taps, the less anxiety she is actually feeling." "She knows that if she taps her fingers she will be able to lessen her anxiety." "The client taps her fingers very rapidly when she is feeling anxious."
"The client taps her fingers very rapidly when she is feeling anxious." Automatisms are automatic, unconscious mannerisms associated with anxiety. Examples include tapping fingers, jingling keys, or twisting hair. Automatisms are geared toward anxiety relief and increase in frequency and intensity with the client's anxiety level. None of the remaining options accurately state the fact that the tapping identifies the level of anxiety a client is experiencing but does not manage or less the emotion.
A client comes to the emergency department because the client thinks the client is having a heart attack. Further assessment determines that the client is not having a heart attack but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to ask? "What did you experience just before and during the attack?" "What do you think caused you to feel this way?" "Do you think you will be able to drive home?" "Are you feeling much better now that you are lying down?"
"What did you experience just before and during the attack?" After it has been determined that the client does not have other medical problems, the nurse should assess for the characteristic symptoms of panic attack, focusing the questions on what the client was experiencing just before and during the attack. Asking the client if the client feels better provides no information for the nurse, and lying down may or may not be effective. Asking the client if the client thinks the client can drive home is a question that can be asked much later in the interview, after the attack subsides and the client is stable. Asking the client about what caused the attack is inappropriate because numerous stimuli, both external and internal, can provoke an attack. Most clients will not be able to identify a specific cause. The focus of care is on the characteristics of the attack.
Which client is most likely to be at risk for drug dependence and difficulties with withdrawal? A woman who has been taking lorazepam for several months after witnessing a traumatic motor vehicle accident A client with generalized anxiety disorder who has responded well since beginning treatment with fluoxetine earlier in the year A man whose obsessive-compulsive disorder is being treated long term with paroxetine A client who has recently begun treatment with propranolol for the treatment of social phobia
A woman who has been taking lorazepam for several months after witnessing a traumatic motor vehicle accident The potential for dependence and difficulties with withdrawal is much higher with benzodiazepines than with beta-blockers or SSRIs.
A client is currently experiencing panic. Which action would be most appropriate for the nurse to do? Urge the client to engage in vigorous exercise Employ the use of negative self-talk Ask the client repeated questions about feelings Allow the client to pace
Allow the client to pace With panic, the nurse should stay with the client. Allow pacing and walk with the client. No content inputs to the client's thinking should be made by the nurse. Asking repeated questions and teaching would be inappropriate because the client is already over-stressed. The client should use positive self-talk. Encouraging vigorous exercise would increase the physiological arousal associated with panic and should be avoided until the client is calm. Exercise should be encouraged for prevention and to promote mental wellness.
A client has sought treatment because of the overwhelming anxiety the client experiences regarding the safety of the client's young children. The client admits that the client will not normally let the client's children leave the client's sight for fear that they will be abducted, abused, or injured. The client is unable to function at work as a result of this anxiety. The nurse would recognize that this client experiences which condition? Fear Derealization Anticipatory anxiety Signal anxiety
Anticipatory anxiety Anticipatory anxiety exists in the context of phobia. People with phobias develop anticipatory anxiety even when thinking about possibly encountering the dreaded phobic situation (i.e., danger to the client's children). The anticipatory anxiety in this case is so severe that the client is unable to function in certain situations leading to hardship. Signal anxiety refers to the natural anxiety mechanism that communicates danger or motivation for needed change. Fear refers to feeling afraid or threatened by a clearly identifiable external stimulus that presents a danger to a person. Derealization refers to a stage in the experience of anxiety when a person senses that things are not real.
A client spends hours stacking and unstacking towels. The client is repeatedly checking to make sure that the towels are in order of color. What term is used to identify this behavior? Compulsion Derealization Obsession Phobia
Compulsion Compulsions are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety. A phobia is an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning. An obsession is a recurrent, persistent, intrusive, and unwanted thought, image, or impulse that causes marked anxiety and interference with interpersonal, social, or occupational function. Derealization is sensing that things are not real.
Clients taking benzodiazepines need education about what? Interactions with monoamine oxidase inhibitors (MAOIs) Avoiding cheeses and smoked meats Concomitant use of alcohol Avoiding spending too much time in the sun
Concomitant use of alcohol Benzodiazepines have long been the drugs of choice for treatment of anxiety disorders. They can induce a physical dependence and can induce severe withdrawal symptoms and intense rebound anxiety when discontinued abruptly. They potentiate the effects of alcohol and other sedative hypnotics, are commonly abused, and have several significant side effects. The most common adverse effects are sedation, ataxia, loss of coordination, slurred speech, memory impairment, paradoxical agitation, and dizziness. They also cause psychomotor impairment.
A young parent tells the nurse, "I can't stop smoking. That is what I do to make myself feel better." What is the term used to describe this behavior? Coping mechanism Caregiver burden Defense mechanism Crisis
Coping mechanism Mild anxiety is often managed without conscious thought by coping mechanisms, which are behaviors used to decrease stress and anxiety. There are many typical behaviors used as coping mechanisms, including smoking.
A client states that the client has just had an argument with the client's spouse over the phone. What can the nurse expect that the client's sympathetic nervous system has stimulated the client's adrenal gland to release? Testosterone Endorphins Dopamine Epinephrine
Epinephrine In the sympathetic-adrenal-medullary response to stress, the sympathetic nervous system stimulates the adrenal gland to release epinephrine and norepinephrine. Corticotropin-releasing factor, adrenocorticotropic hormone (ACTH), and glucocorticoids are released in the hypothalamic-pituitary response to stress.
Which assessment question is most likely to allow the nurse to differentiate between anxiety disorder due to a general medical condition and psychological factors affecting a medical condition? Establishing whether the client's anxiety preceded the medical problem or whether the medical problem appeared first Asking the client to provide a detailed explanation of his or her medical problem to determine if the presentation is typical of the problem Questioning the client about the clinician who first diagnosed the medical problem Reviewing the client's previous medication administration record and the client's current list of medications
Establishing whether the client's anxiety preceded the medical problem or whether the medical problem appeared first Considering the relationship of anxiety with the onset, exacerbation, or remission of the general medical condition can help determine whether a medical condition contributes to anxiety or vice versa. The client's medication list, the identity of the clinician who diagnosed the disease, and the client's symptoms are all aspects of the assessment process, but these are less likely to establish the primary cause.
The nurse is assessing a client and finds two enlarged supraclavicular lymph nodes. The nurse asks the client how long these enlarged nodes have been there. The client states, "I can't remember. A long time I think. Do I have cancer?" The nurse is aware that that body responds to stress. Which is an immediate physiologic response to stress the nurse would expect to see in this client? Increased blood pressure Pupil constriction Vasodilation of peripheral blood vessels Decrease in blood glucose levels
Increased blood pressure An initial response to stress, as seen by the fight-or-flight response, is an increase in the client's heart rate and blood pressure. Vasoconstriction leads to the increase in blood pressure. Blood glucose levels increase, supplying more readily available energy, and pupils dilate.
An adolescent client reveals that she is about to take a math test from her tutor. Nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety does what? Will interfere with her cognitive abilities Is conducive to concentration and problem solving May be transferred to her tutor and result in test anxiety Is pathologic and warrants postponing the test
Is conducive to concentration and problem solving Mild anxiety is often helpful to individuals and can assist in maintaining concentration and problem-solving abilities. Moderate to severe anxiety can begin to inhibit an individual's coping because these levels create physiologic responses (such as tachycardia and sweating) and psychological responses (such as loss of concentration and inability to focus) that may prevent the person from functioning adequately, interfere with cognitive abilities, and become pathologic if not treated adequately.
During which type of anxiety does a person's perceptual field actually increase? Panic Moderate Severe Mild
Mild During mild anxiety, a person's perceptual field widens slightly, and the person is able to observe more than before and to see relationships. During moderate anxiety, the perceptual field narrows slightly. The person does not notice what goes on peripheral to the immediate focus but can do so if attention is directed there by another observer. The perceptual field is greatly reduced in severe anxiety. During panic anxiety, the perceptual field is reduced to a detail, which is usually "blown up."
When a client is experiencing panic, which is the priority intervention? Physically restrain the client. Move the client to a quiet environment. Offer the client therapy to calm down. Give the client medication immediately.
Move the client to a quiet environment. Decreasing external stimuli will help lower the client's anxiety level. The client's safety is priority. Anxious behavior can be escalated by external stimuli. In a large area, the client can feel lost and panicked, but a smaller room can enhance a sense of security. Medicating the client would be inappropriate. Restraint should only be used as a last resort. Therapy can be appropriate once the client's anxiety level decreases.
The nurse has read in a client's admission record that the client has been taking propranolol for psychiatric, rather than medical, reasons. The nurse should recognize that the client likely has a history of which mental health condition? Obsessive-compulsive disorder (OCD) Panic disorder Nightmares Acute stress disorder
Panic disorder Propranolol is used in the treatment of panic disorder, but it is not a common pharmacological intervention for OCD, acute stress disorder, or nightmares.
Relaxation techniques help clients with anxiety disorders because they can promote what? Increase in sympathetic stimulation Reduction of autonomic arousal Release of cortisol Increase in the metabolic rate
Reduction of autonomic arousal Regularly inducing the relaxation response reduces the general level of autonomic arousal in anxious clients. It lowers blood pressure, heart rate, metabolic rate, and oxygen demands. This physiologic effect may result from effects on the production of cortisol, a hormone the body releases in response to stress. Cortisol is helpful during the fight-or-flight response, but its prolonged presence in chronically anxious or stressed clients can inhibit the immune system and have other deleterious effects on the body.
Which should be included in a teaching plan for a client prescribed a benzodiazepine? Stop taking drug if sedation develops Consume caffeine in moderation Maintain a fluid restriction Rise slowly from a lying or sitting position
Rise slowly from a lying or sitting position Clients taking a benzodiazepine should rise slowly from a lying or sitting position. The client should drink adequate fluids, avoid caffeine, and not stop taking the drug abruptly.
A 30-year-old client who has been unemployed secondary to anxiety disorder states that the client would like to have a job where the client is alone and no one needs to evaluate the client's work. The nurse interprets these comments as an indicator of what? Obsessive-compulsive disorder Panic disorder Agoraphobia Social phobia
Social phobia Social phobia represents a persistent, irrational fear of and compelling desire to avoid situations in which the person may be exposed to unfamiliar people or to the scrutiny of others. Additionally, the person harbors the fear of behaving in a way that may prove humiliating or embarrassing. The person will experience marked anticipatory anxiety if confronted with such a situation and will attempt to avoid it.
Which condition involves a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger? Posttraumatic stress disorder Generalized anxiety disorder Specific phobia Obsessive-compulsive disorder
Specific phobia Specific phobia is a disorder marked by persistent fear of clearly discernible, circumscribed objects or situations, which often leads to avoidance behaviors. Posttraumatic stress disorder can occur following exposure to an actual or threatened traumatic event such as death, serious injury, or sexual violence. In obsessive-compulsive disorder, affected clients have both obsessions and compulsions and believe that they have no control over them, which results in devastating consequences for the individuals. Generally speaking, clients with generalized anxiety disorder feel frustrated, disgusted with life, demoralized, and hopeless. They may state that they cannot remember a time that they did not feel anxious. They experience a sense of ill-being and uneasiness and a fear of imminent disaster.
Which would be an appropriate intervention for a client experiencing an anxiety attack? Turning on the lights and opening the windows so that the client does not feel crowded Leaving the client alone Staying with the client and speaking in short sentences Turning on stereo music
Staying with the client and speaking in short sentences Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm, and medicating as needed. Leaving the client alone, turning on a stereo or lights, and opening windows may increase the client's anxiety.
A client who experiences panic anxiety around dogs is sitting in a room with a dog and the client's nurse therapist. The nurse therapist is using which behavioral intervention for this type of anxiety? Relaxation exercise Biofeedback Implosion therapy Systematic desensitization
Systematic desensitization Systematic desensitization refers to the exposure of a person to a fear-producing situation in a systematized manner to decrease a phobic disorder. Implosion therapy, while similar, is not the technique described in this option. This scenario lacks the physical control techniques implemented by relaxation exercise, and it lacks the auditory and/or visual techniques implemented by biofeedback.
A group of nursing students are reviewing signs and symptoms of anxiety. The students demonstrate a need for additional review when they identify what? Tearfulness Motor excitement Palpitations Extreme restlessness
Tearfulness The clinical symptoms of anxiety are numerous. They are generally classified as physiologic, psychological or emotional, behavioral, and intellectual or cognitive responses to stress. The clinical symptoms may vary according to the level of anxiety exhibited by the client. Tearfulness and sadness are symptoms of depression, not of anxiety.
All except which are considered clinical symptoms of anxiety? Tearfulness and sadness Motor excitement Palpitations Extreme restlessness
Tearfulness and sadness The clinical symptoms of anxiety are numerous. They are generally classified as physiologic, psychological or emotional, behavioral, and intellectual or cognitive responses to stress. The clinical symptoms may vary according to the level of anxiety exhibited by the client. Tearfulness and sadness are symptoms of depression, not of anxiety.
A client reports the client has been experiencing increased stress at work. The client has been managing the stress by drinking 2-3 glasses of wine per evening. Despite the nurse recommending that drinking alcohol is not an effective way to manage the stress, the client reports it is unlikely that the client will be able to stop. Which statement explains why this will be difficult for the client? A few glasses of wine each night is not necessarily a problem. Drinking alcohol is more socially acceptable than taking medications. The client is probably physically dependent on alcohol. The client has no adaptive coping mechanisms.
The client has no adaptive coping mechanisms. Clients learn to reduce the anxiety they feel in either functional or dysfunctional ways. The nurse first explores with the client what techniques the client has used in the past and helps the client identify and enhance those strategies that are most beneficial. The nurse and client identify maladaptive coping strategies, such as social withdrawal or alcohol use, and replace them with adaptive strategies that suit the client's personal, cultural, and spiritual values. The nurse should not ask the client to give up coping mechanisms, even maladaptive ones, without offering other adaptive mechanisms.
The nurse is assessing a client with anxiety. Which behavior might indicate that the client has moderate anxiety? The client is unable to communicate verbally. The client has impaired cognitive skills. The client is nervous and agitated. The client is focused in an activity.
The client is nervous and agitated. A client who is moderately anxious has a disturbing feeling that something is wrong. This causes nervousness and agitation. Increased concentration and attention is seen in clients having mild anxiety. Cognitive skills are impaired in clients who have severe anxiety. Inability to communicate verbally indicates that the client is panicking.
In speaking with a client with moderate anxiety, the client becomes tangential discussing unrelated topics. To help the client's attention from wandering, which is an effective intervention? The nurse should speak in a soft and calm voice. The nurse should remain with the client until the anxiety is reduced. The nurse should speak in short and simple sentences. The nurse should take the client to a nonstimulating environment.
The nurse should speak in short and simple sentences. Speaking in short, simple, and easy-to-understand sentences has been shown to be effective with clients with moderate anxiety whose attention wanders. Not leaving the client alone unless the anxiety is reduced and speaking in a soft voice are interventions used with a client with severe anxiety. If the client has panic-level anxiety, the nurse should give primary attention to the safety of the client and move the client to a nonstimulating environment.
Which nursing intervention is focused on the primary goal of anxiety management and treatment? helping the client identify ways to eliminate all sources of stress in his or her daily life assessing the client's ability to implement stress management techniques effectively educating the client concerning the use of medications to manage anxiety disorders assessing the client for possible symptoms of panic disorder
assessing the client's ability to implement stress management techniques effectively For people with anxiety disorders, it is important to emphasize that the goal is effective management of stress and anxiety, not the total elimination of anxiety. Learning anxiety management techniques and effective methods for coping with life and its stresses is essential for overall improvement in life quality. Although medication is important to relieve excessive anxiety, it does not solve or eliminate the problem entirely. While assessment is appropriate, it is not directly associated with the management and treatment of the original disorder.
A nurse is seeing a client who is having severe to panic level anxiety after a physical assault months previously. The client tells the nurse, "When the panic starts I feel like I am watching myself through a window." The nurse can most accurately describe this experience as: decatastrophizing. depersonalization. derealization. demonstrating automatisms.
depersonalization. Depersonalization is a feeling that the client may describe as being disconnected from herself, such as watching oneself. This is common when individuals experience panic levels of anxiety. Derealization refers to the sensation that things are not real or surreal during panic levels of anxiety. Decatastrophizing refers to a treatment approach used by therapists in which the client is asked questions in order to urge the client to develop a more realistic appraisal of the situation causing the anxiety. Automatisms are automatic, unconscious mannerisms that are geared toward relief of anxiety and increase in intensity and frequency with a rise in the client's anxiety level.
An adolescent who is seeing the school health nurse states, "I won't be able to hang out with my friends on Friday night because I have two essays due Monday." What level of anxiety is the adolescent experiencing? severe mild panic moderate
mild Mild anxiety is characterized by an increase in sensory stimulation that is helping the adolescent focus attention to achieve a goal. The anxiety is positive because it motivates the adolescent but does not interfere with social, occupational, or emotional functioning. The adolescent is still able to concentrate independently without having to be redirected to the topic. Moderate anxiety is characterized by a disturbing feeling that something is wrong. With moderate anxiety, a person can still process information but may have some trouble with concentration and require redirecting to focus. Severe anxiety is characterized by a significant decrease in a person's cognitive skills. If severe anxiety was being experienced, the adolescent would likely have trouble thinking and reasoning. Panic level of anxiety is characterized by physiological responses to anxiety that take over the ability to reason leading to diminished cognitive skills. It would be nearly impossible for the adolescent to make any decisions about how to organize time to complete homework if panic level of anxiety was being experienced.
Which statement, made by a client diagnosed with an anxiety disorder, should trigger the nurse's concern about the client's understanding of the use of defense mechanisms? "I'm not sure when I'm actually using a defense mechanism." "I'm thankful that I have a way to manage my problems." "When I have a problem, I just deny it until it goes away." "Defense mechanisms provide a sense of control over the uncontrollable."
"When I have a problem, I just deny it until it goes away." The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. Denial should not be used to deal with all of one's problems. None of the remaining options present untrue or troubling statements regarding defense mechanisms.
The nurse is caring for a client diagnosed with anxiety disorder. The client is demonstrating difficulty concentrating and is preoccupied with feelings of helplessness. When creating the plan of care, which goal would be most appropriate for this client? The client will avoid stimuli that induces anxiety. The client will identify the source of anxiety. The client will display ability to cope with anxiety. The client will show interest in activities.
The client will display ability to cope with anxiety. Coping is a process used by individuals to manage anxiety, and may be effective or ineffective. Anxiety disorders are diagnosed when anxiety no longer functions as a signal of danger, or a motivation for needed change but becomes chronic and permeates major portions of the person's life, resulting in maladaptive behaviors and emotional disability. Nurses encounter anxious clients and families in a variety of situations. The nurse must first assess the person's anxiety level because this determines what interventions are likely to be effective. When working with an anxious person, the nurse must remain calm and in control. The goal for the client with anxiety is ultimately to be able to cope with anxiety. During the treatment the client will have to identify the source of anxiety, be able to adapt to stimuli that produces anxiety, and show interest in activities that previously caused anxiety.
A nurse is caring for a client who has panic attack. The nurse takes the client in a small, isolated room. How would this intervention benefit the client? Choose the best answer. The client would have an enhanced sense of security. The client would be able to understand what the nurse is saying. The client would be able to demonstrate relaxation techniques. The client would return to rational thought.
The client would have an enhanced sense of security. A client with panic-level anxiety should be taken to a small, isolated room. This is to reduce any external stimuli that could escalate anxiety. Taking the client to a small room would make the client feel more protected and secured. A client experiencing a panic attack may lose rational thought; however, this intervention would not directly improve thought processes. The client would not be able to demonstrate relaxation techniques in a panic laden state. This intervention would not enhance the client's ability to understand what the nurse is saying.
Which would not be an initial intervention for the client with acute anxiety? Touching the client in an attempt to comfort the client Maintaining a nonstimulating environment Encouraging the client to verbalize feelings and concerns Use of open-ended communication techniques
Touching the client in an attempt to comfort the client The nurse should evaluate carefully the use of touch because clients with high anxiety may interpret touch by a stranger as a threat and pull away abruptly. Use open-ended questions, encouraging the client to verbalize feelings and concerns, and maintain a nonstimulating environment.
A school health nurse is meeting with the parents of a 6-year-old child who has been selectively mute. The nurse is offering the parents education regarding this problem. The nurse can tell the parents that what is true about selective mutism? parenting does not play a role in selective mutism selective mutism arises from child abuse children with selective mutism should be home-schooled. selective mutism is associated with social anxiety
selective mutism is associated with social anxiety Selective mutism is diagnosed in children when they fail to speak in social situations even though they are able to speak. There is a high level of social anxiety in these situations. It would be most accurate for the nurse to explain to the parents that selective mutism is associated with social anxiety. Parenting plays a role in perpetuating selective mutism because there is a cycle of avoidance that can be enabled or encouraged when the child continuously wants to avoid social settings. Selctive mutism does not necessarily arise from child abuse. Factors such as a shy disposition or family history of anxiety are most likely to be associated with selective mutism. By home-schooling a child who displays selective mustism, opportunities to learn to manage anxiety through exposure to the anxiety provoking stimuli (social settings) are lost. The child learns that avoiding is a healthy way of managing anxiety.
The nurse is providing care for a psychiatric-mental health client who has a diagnosis of anxiety. Which statement by the nurse is likely the most therapeutic intervention? "Every time you feel anxious, try to focus on how much easier your life would be if you didn't experience anxiety so often." "If you address the causes of your anxiety head-on, you will find that you can recover from it without medications or therapy." "With the development of more life skills and a demonstration of continued success in life, your anxiety will shrink and eventually disappear." "Anxiety is a feeling that is experienced by everyone at some point and it can never be completely removed from one's life."
"Anxiety is a feeling that is experienced by everyone at some point and it can never be completely removed from one's life." It is therapeutic to foster in clients the understanding that the experience of anxiety is natural and inevitable. It would be inaccurate to promise recovery with increased success in life and self-discipline. Clients with anxiety are likely to be well aware of how much easier their lives would be without recurring anxiety.
Which question in the assessment of a client with anxiety is most clinically appropriate? "Do you think that you're justified in feeling anxious right now?" "Does your anxiety make you feel less valuable and competent as a person?" "What can I give you to make you feel less anxious right now?" "How do you feel about everything that is happening in your life right now?"
"How do you feel about everything that is happening in your life right now?" An open-ended question that prompts the client to describe his or her current feelings is a useful assessment technique. Offering medications or other solutions, asking if the client feels justified in his or her feelings, and questioning the client's self-worth are not normally appropriate, or effective, assessment techniques.
A hospitalized client states that the client is having difficulty resting. Which intervention would help promote rest? Assisting the client with deep-breathing exercises Encouraging the client to take prescribed sedatives daily Offering the client a cup of tea Leaving the client's door open so the client can see into the hallway
Assisting the client with deep-breathing exercises Deep-breathing exercises are beneficial to promoting rest as they help the client to relax. The client's door should be closed to reduce noise and distractions. Tea contains caffeine, which acts as a stimulant. While sedatives may be used occasionally for assistance with rest, regular use isn't advised because dependence may develop.
A nurse is preparing a plan of care for a client with anxiety. Which would the nurse likely include? Select all that apply. Using restraint when panic develops Providing supportive feedback Identifying treatment modalities Using appropriate coping skill Involving family for support, if appropriate
Using appropriate coping skill Identifying treatment modalities Involving family for support, if appropriate Providing supportive feedback Appropriate measures to include in the plan of care for a client with anxiety include: introducing appropriate coping skills, identifying alternate treatment modalities, involving family and support persons when appropriate, and providing feedback that is supportive to the client. Restraint is always a last resort.