A patient states, 'I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up.' Which nursing intervention should have the highest priority?

Correct Answer: D

Rationale: The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

Correct Answer: B

Rationale: In this scenario, the most appropriate intervention is option B) Teach the patient relaxation techniques to help manage anxiety. Generalized anxiety disorder is characterized by excessive and uncontrollable worry about various aspects of life. Teaching the patient relaxation techniques such as deep breathing, progressive muscle relaxation, or mindfulness can help them cope with their anxiety symptoms effectively. Option A) Encouraging the patient to confront their anxieties head-on may exacerbate their anxiety and lead to increased distress. Patients with generalized anxiety disorder often find it challenging to confront their worries directly without proper coping mechanisms in place. Option C) Reassuring the patient that their worries are unfounded and unimportant may invalidate their feelings and experiences, potentially worsening the therapeutic relationship and diminishing the patient's trust in the nurse. Option D) Encouraging the patient to avoid stressful situations whenever possible is not a recommended approach as it promotes avoidance behavior, which can further reinforce anxiety in the long term. It is essential to empower patients with coping strategies rather than avoidance tactics. Educationally, it is crucial for nurses to understand the evidence-based interventions for managing generalized anxiety disorder. By teaching relaxation techniques, nurses empower patients to take an active role in managing their symptoms and promote self-care practices that can enhance their overall well-being. This rationale highlights the importance of individualized, patient-centered care in addressing mental health challenges like generalized anxiety disorder.

Correct Answer: A

Rationale: A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.

Correct Answer: C

Rationale: In this scenario, the most appropriate nursing intervention is option C: Set firm limits on the patient's behavior to prevent harm. When working with a patient in the manic phase of bipolar disorder, setting firm limits is crucial to ensure their safety and the safety of others. Manic episodes can lead individuals to engage in risky behaviors that may result in harm or consequences. By establishing clear boundaries, the nurse can help manage the situation and prevent any potential negative outcomes. Option A, providing a calm and quiet environment, may not be sufficient in addressing the risky behaviors associated with mania. While a calming environment can be beneficial in some cases, it may not effectively manage the impulsivity and poor judgment often seen in manic episodes. Encouraging the patient to express their feelings and talk about their behavior (option B) may not be appropriate during a manic phase as the patient's judgment and insight may be impaired. Engaging in such discussions could potentially reinforce or escalate the risky behaviors. Option D, allowing the patient to engage in whatever activities they choose without interference, is not recommended as it could further exacerbate the situation and increase the risk of harm. Patients in a manic phase may not be able to make sound decisions, making it necessary for the nurse to intervene and provide structure and boundaries. In an educational context, understanding the importance of setting firm limits during manic episodes is crucial for nurses working in behavioral health settings. It showcases the significance of safety measures and the role of the nurse in managing challenging behaviors associated with bipolar disorder. By choosing the correct intervention, nurses can effectively support patients in crisis and promote their overall well-being.

Correct Answer: C

Rationale: Asking, 'Am I correct in understanding that "¦' permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.