Anxiety.docx - Question 1(see full question You selected...

Question 1:
(see full question)
The client rushes out of the day room where he has been watching
television with other clients. He is hyperventilating and flushed and his fists
are clenched. He states to the nurse, “That bastard! He is just like Tom. I
almost hit him.” What would be the nurse’s best response?
You selected: "You are angry, and you did well to leave the situation. Let us walk up and
down the hall while you tell me about it.”
Correct
Explanation: The nurse acknowledges and labels the client’s emotion and
acknowledges his appropriate behavior. Recognizing the client’s
physiologic arousal, the nurse suggests an activity to decrease anxiety
and stays with him.
Setting limits on the client’s language does not acknowledge his control
and does not help the client manage his anxiety.
The client needs to engage in physical activity to decrease muscle tension
and anxiety.
Offering the client medication suggests that he cannot control his behavior.
Medication would be used only if other interventions failed to reduce the
anxiety level.
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Question 2:
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A client was admitted to the inpatient unit 3 days ago with a flat affect,
psychomotor retardation, anorexia, hopelessness, and suicidal ideation.
The health care provider (HCP) prescribed 75 mg of venlafaxine extended
release to be given every morning. The client interacted minimally with the
staff and spent most of the day in his room. As the nurse enters the unit at
the beginning of the evening shift, the client is smiling and cheerful and
appears to be relaxed. What should the nurse interpret as the most likely
cause of the client’s behavior?
You selected: The client's sudden improvement calls for close observation by the staff.
Correct
Explanation: The client’s sudden improvement and decrease in anxiety most likely
indicate that the client is relieved because he has made the decision to kill
himself and may now have the energy to complete the suicide. Symptoms
of severe depression do not suddenly abate because most
antidepressants work slowly and take 2 to 4 weeks to provide a maximum
benefit. The client will improve slowly due to the medication. The sudden
improvement in symptoms does not mean the client is nearing discharge,
and decreasing observation of the client compromises the client’s safety.
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Question 3:
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The client, who is a veteran and has posttraumatic stress disorder, tells
the nurse about the horror and mass destruction of war. He states, “I killed
all of those people for nothing.” Which response by the nurse is
appropriate?
You selected: "You did what you had to do at that time."
Correct
Explanation: The nurse states, “You did what you had to do at that time,” to help the
client evaluate past behavior in the context of the trauma. Clients
commonly feel guilty about past behaviors when viewing them in the
context of current values. The other statements are inappropriate because
they do not help the client to evaluate past behavior in the context of the
trauma. ( less )