Real Life RN: Anxiety Disorder

Nurse T is communicating with Ms. S. Which is an appropriate action for T to take?

Restate Ms. S's concern restating the clients concerns allows for exploration and clarification of the clients statements

Nurse T is calculating the dose of lorazepam. Available 4mg/mL. How many mL should the nurse admin?

0.5ml 4mg x 2mg ------------ 1ml x ml = 0.5ml

Nurse T has discovered Ms. S self-injury. Which thought processes is most likely a reflection of Ms. S behavior?

Alleviation of psychological pain self-injury is a mode of alleviating psychological pain caused by physical pain

Nurse T admit Ms. S. Priority action for T to take?

Assess respiratory status

Nurse T is discussing Ms. S is most stressful situation. Which actions should T take first?

Continue to gather more information regarding finances 1st solution is to COLLECT DATA

Nurse T is listening to Ms. S while she describes the stressors that contribute to her anxiety. Which coping mechanisms is Ms. S. exhibiting?

Denial Displacement Rationalizing Splitting is the inability to blend both the positive and negative qualities of self. The client knowing that her bf will return is an example of denial. Denial involves the conscious effort of not thinking about an unpleasant event or occurrence that is causing stress. The client blaming the bf drinking and gambling behavior to be the cause of her inability to pay rent is an example of displacement. Displacement happens when there is a transfer of feelings about an individual or circumstance to another person or object that is uninvolved in the situation. The client stating that she will be fine without assistance is an example of rationalization. Rationalization is the belief in or acting upon an idea that is unrealistic in order to satisfy the response of the communicator and the listener. Regression involves the acting out behaviors of an individual at an earlier stage in life

Nurse T assess Ms. S. Which assessment scales is appropriate?

Hamilton-A CLient has SOB, chest pain, H/a, restlessness and trembling

Nurse T is explaining Ms. S diagnosis. Which statements should T include in the teaching?

Interventions are based on the degree of anxiety you are experiencing. You can experience four levels of anxiety. (mild, moderate, severe, panic) It is common to perform repetitive behaviors in order to cope with anxiety. (handwashing)

Nurse T completes the Hamilton-A assessment of Ms. S and determines her score to be 26. Which appropriate action for the nurse to take?

Lorazepam A score of 26 on the Hamilton-A assessment indicates severe level of anxiety. Therefore, obtaining a prescription for lorazepam is appropriate. Clients who have a severe level of anxiety should receive a short-acting benzodiazepine, such as lorazepam as an anxiolytic agent

Nurse T preparing to call provider. List the findings.

S (Situation) = Ms. Simpson is a 22-year-old African-American female admitted to the inpatient mental health unit for anxiety. She is restless and fidgety, has poor concentration, and has been experiencing chest pain and shortness of breath. B (Background) = She has a history of generalized anxiety disorder and has previously taken paroxetine 20 mg PO daily, but has not been taking it for approximately 2 weeks. A (Assessment)= Her vital signs from report at 0745 were: heart rate 115, blood pressure 148/76, respirations 32, oxygen saturation 96% on room air, and temperature 37.0 C (98.6 F). Her score on the Hamilton A scale is 26, and she has been unable to focus on answering questions due to her severe level of anxiety. She continues to pace, wring her hands, and rock when sitting. R (Recommendation) = I am calling to request a prescription for lorazepam.

Nurse T is teaching Ms. S about anxiety. Which indicate Ms. S understands the teaching?

Uses relaxation techniques

Nurse T is initiating therapeutic communication with Ms. S. Which video best?

Video 3 You say you have been feeling overwhelmed tell me what has been going on in our life, whats most concerning you, -Can't pay my bills and my Bf broke up with me -Engaged and active listening, including direct eye contact, are key principles of effective communication and will assist in building rapport with the client

Nurse T is providing medication teaching regarding escitalopram. Which statements should T include in the teaching?

You should report increased thoughts of suicide. escitalopram therapy increases the risk for suicidal ideation