STAT Stitch Deep Dive Podcast Beyond The Bedside

STAT Stitch Deep Dive Podcast Beyond The Bedside

by Regular Guy

Courses Life Sciences

Season 6

MH | Therapeutic Relationships

Core Components Establishing therapeutic relationships is the crucial underpinning for psychiatric nursing interventions. Trust & Congruence: Trust builds when a nurse’s words and actions match, which is known as congruence. Empathy vs. Sympathy: Empathy is accurately perceiving the client's feelings, whereas sympathy involves projecting personal concerns or pity, which shifts the focus to the nurse and encourages client dependency. Acceptance & Positive Regard: Nurses must avoid judgments, set firm boundaries without anger, and show unconditional respect. Self-Awareness Nurses must first understand their own values and biases to develop a therapeutic use of self. Johari Window: This tool assesses self-awareness across open, blind, hidden, and unknown quadrants. Patterns of Knowing: Carper identified empirical (science), personal (experience), ethical (moral), and aesthetic (art) knowledge, while Munhall added "unknowing"—avoiding preconceptions to authentically hear clients. Relationship Types Social & Intimate: Social relationships are for friendship, and intimate relationships involve emotional or sexual commitment. Therapeutic: This strictly focuses on the client’s needs with clear parameters, and slipping into social or intimate interactions erodes professional boundaries. Peplau’s Phases of the Relationship Orientation: Roles, problems, boundaries, and contracts (time and place) are established. The nurse outlines confidentiality limits and must never keep secrets regarding self-harm. The duty to warn (Tarasoff decision) mandates reporting homicidal threats to supervisors, police, and intended victims. Working: This phase is divided into problem identification and exploitation, focusing on exploring feelings and developing coping mechanisms. The nurse must recognize transference (the client unconsciously transferring feelings onto the nurse) and countertransference (the nurse responding based on personal unconscious conflicts). Termination: This is the final phase when goals are met. Clients may exhibit anger or stall to avoid the impending loss; the nurse must validate these feelings but never agree to see the client socially. Nursing Roles Nurses serve as a teacher (educating on coping), caregiver (building trust), advocate (protecting safety, even if it opposes the client's wishes), and parent surrogate (setting firm limits if clients act childlike). Boundaries & Red Flags Boundary violations often begin unintentionally. Self-disclosure should be rare, purposeful, and focus on resolved past issues rather than current struggles. Red flags include feeling sympathy, accepting gifts, keeping secrets, spending off-duty time with clients, and avoiding clients due to unresolved personal prejudices.

MH | Therapeutic Communication

1. Core Principles & Message Congruency Content vs. Process: Communication involves verbal content and nonverbal process (body language, tone). When messages are incongruent, the nonverbal behavior is always the more accurate reflection of the client's true feelings. Concrete vs. Abstract: Always use explicit, concrete language. High anxiety and cognitive impairment reduce processing ability, making abstract figures of speech and metaphors confusing or dangerous. Active Listening: This requires refraining from planning your next question. The nurse should build follow-up questions directly from the client's overt or covert cues. 2. High-Risk Safety & Boundaries Proxemics: The ideal therapeutic distance is 3 to 6 feet. The intimate zone (0 to 18 inches) is threatening; invading it requires clear permission. Touch Restrictions: Touch is generally avoided in psychiatric settings. Clients with trauma histories or paranoia may interpret touch as a violent threat and strike out. Always verbally prepare the client before touching. Covert Cues & Suicide Risk: Covert cues are vague statements (e.g., "Sleep is good... forever"). The priority action is to clarify intent using direct, concrete, yes-or-no questions about suicidal ideation (e.g., "Are you planning to kill yourself?"). 3. Essential Therapeutic Techniques (The "Do's") Broad Openings: Asking "Where would you like to begin?" gives the client control over the interaction. Presenting Reality: Calmly state what is real ("I see no one else in the room") without arguing with or belittling the client's misinterpretations. Reflecting: Direct the client's actions or feelings back to them, promoting independent decision-making. Silence: Expectant silence gives the client time to organize thoughts or regain composure. 4. Dangerous Nontherapeutic Techniques (The "Don'ts") Asking "Why": Asking a client "why" they feel a certain way is intimidating and triggers defensiveness. Giving Advice: Telling the client what to do implies the nurse knows best, stripping the client of autonomy. False Reassurance: Saying "Everything will be alright" devalues the client's severe distress. Challenging: Demanding proof for delusions only causes the client to defend their misperceptions more fiercely. 5. Clinical Interventions & Assertiveness Directive vs. Nondirective: Use a nondirective role (open-ended questions) to let the client lead. Switch to a directive role (direct, yes-or-no questions) during emergencies like suicide risk or psychosis. Problem-Solving: The nurse must guide—never dictate—problem-solving. Clients must choose their own solutions to build self-esteem and ensure follow-through. Assertive Communication: Rely on calm, factual "I" statements. Use the "broken record technique" (repeating a firm refusal without offering justifications) to safely maintain boundaries against persistent requests.

MH | Neurobiology and Psycho Pharmacology

The 20% That Matters Most: Must-Know Medications & Safety Red Flags Antipsychotics (for Schizophrenia/Psychosis) Extrapyramidal Symptoms (EPS): Include acute dystonia (severe muscle cramping/spasms), akathisia (intense internal restlessness), and pseudoparkinsonism. Priority action: Treat immediately with anticholinergics like benztropine (Cogentin) or diphenhydramine. Tardive Dyskinesia (TD): Irreversible involuntary movements (e.g., lip-smacking, tongue thrusting) caused by long-term use. Priority: Prevention and monitoring using the Abnormal Involuntary Movement Scale. Neuroleptic Malignant Syndrome (NMS): A rare, fatal idiosyncratic reaction. Red Flags: Extreme muscle rigidity, high fever, and autonomic instability (unstable blood pressure). Priority action: Stop the drug immediately and provide supportive medical care. Clozapine (Clozaril): An atypical antipsychotic that causes agranulocytosis (a life-threatening drop in white blood cells). Priority: Mandatory weekly WBC monitoring; immediately evaluate any signs of infection, such as a sore throat or fever. Metabolic Syndrome: Atypical antipsychotics frequently cause severe weight gain, diabetes, and hyperlipidemia, which significantly increases cardiovascular risk and causes poor medication adherence. Antidepressants (SSRIs, SNRIs, TCAs, MAOIs) Suicide Risk: The highest risk occurs early in treatment. The medication increases the patient's energy levels before their depressed mood lifts, giving them the energy to carry out a suicide plan. MAOIs (e.g., Phenelzine): Interacts fatally with the amino acid tyramine. Red Flag: Ingesting aged cheeses, cured meats, or tap beer causes a life-threatening hypertensive crisis. Serotonin Syndrome: A fatal interaction (agitation, fever, tachycardia, rigidity) often caused by mixing SSRIs with MAOIs. One drug must completely clear the system before starting the other. Mood Stabilizers (Bipolar Disorder) Lithium: Has a very narrow therapeutic window (target ~1 mEq/L). Red Flag for Toxicity: Levels >1.5 mEq/L cause severe diarrhea, vomiting, muscle weakness, and lack of coordination. Toxic levels can quickly lead to renal failure, coma, or death. Anticonvulsants: Lamotrigine can cause Stevens-Johnson syndrome, a life-threatening rash requiring hospitalization. Valproic Acid carries severe black-box warnings for hepatic failure and life-threatening pancreatitis. Anxiolytics, Stimulants & Substance Abuse Benzodiazepines (Anxiolytics): Potentiate GABA. Red Flags: Never mix with alcohol due to extreme CNS depression, and never discontinue abruptly because withdrawal can be fatal. Disulfiram (Antabuse): Deterrent for alcohol use. Causes severe vomiting, flushing, and severe hypotension if mixed with alcohol. Priority teaching: Avoid all hidden alcohol, including mouthwash, aftershave, and over-the-counter cough medicines. Stimulants (ADHD): Can cause anorexia and growth suppression. Priority teaching: Give doses after meals and schedule "drug holidays" (e.g., during summer vacation) to allow for normal growth and eating patterns.

MH | Psycho Theories and Tx

Psychoanalytic and Interpersonal Foundations Sigmund Freud’s psychoanalytic theory states human behavior is driven by unconscious, repressed desires. He identified three personality components: the id (impulsive, pleasure-seeking), the superego (moral values), and the ego (the mediating force). To protect the ego from emotional pain, humans use unconscious ego defense mechanisms like denial, projection, and rationalization. Freud defined transference, where clients displace feelings from past relationships onto the therapist, and countertransference, where therapists displace their past feelings onto clients. Building on Harry Stack Sullivan’s interpersonal theories, Hildegard Peplau established the four phases of the therapeutic nurse-patient relationship: orientation, identification, exploitation, and resolution. Peplau crucially categorized anxiety into four levels: mild (sharpened senses), moderate (limited perceptual field), severe (dread, tachycardia), and panic (loss of rational thought, immobility). Developmental and Humanistic Models Erik Erikson defined eight psychosocial stages across the lifespan, such as Trust vs. Mistrust for infants, where successful completion of each task yields a virtue like hope or wisdom. Jean Piaget added four stages of cognitive development: sensorimotor, preoperational, concrete operations, and formal operations. Abraham Maslow’s hierarchy of needs dictates that basic physiological needs and safety must be met before progressing to higher-level needs like love, esteem, and self-actualization. Carl Rogers’ client-centered therapy dictates that nurses must provide unconditional positive regard, genuineness, and empathetic understanding. Behavioral, Cognitive, and Existential Theories Behaviorism, via B.F. Skinner’s operant conditioning, focuses on observable behaviors, asserting that behaviors followed by positive reinforcement will recur. This forms the basis for behavior modification, token economies, and systematic desensitization. Cognitive Behavioral Therapy (CBT) focuses on altering faulty thinking to relieve distress. Dialectical Behavior Therapy (DBT), a specialized CBT, teaches distress tolerance and emotional regulation, making it effective for suicidal clients and borderline personality disorder. Existential therapies, like reality therapy, challenge clients to examine how behavior thwarts life goals, encouraging personal responsibility. Crisis Intervention and Modalities A crisis is an overwhelming emotional response to a stressor that typically resolves in four to six weeks. Crises are categorized as maturational (predictable life events), situational (sudden loss), or adventitious (natural disasters). Effective crisis intervention provides early directive and supportive strategies to aid coping. Treatment modalities feature group therapy, which progresses through beginning, working, and termination stages. Group roles can be growth-producing (harmonizer) or growth-inhibiting (monopolizer). Modern care prioritizes psychiatric rehabilitation to help clients with severe mental illnesses manage symptoms and live successfully in the community.

MH | Psycho Assessment

Critical Factors Influencing the Assessment Nurses must manage several variables that can compromise the accuracy of their data: Client Health Status: Pain, fatigue, or high anxiety severely limit participation. The nurse must prioritize addressing these acute physical or emotional needs before continuing the full assessment. Previous Experiences & Trust: Clients with past negative healthcare experiences or reluctance to seek treatment may minimize or maximize symptoms. The nurse's first priority is to establish a safe, trusting environment. Nurse’s Approach: A judgmental, defensive, or rushed attitude will cause clients to withhold sensitive information (e.g., domestic violence or substance use). The nurse must maintain a matter-of-fact, nonjudgmental tone. Safety & Environment: Conduct the interview in a private, quiet setting to minimize distractions. However, never choose an isolated room if the client has a history of threatening behavior; safety for both the nurse and client is always paramount. Communication Strategies: Begin with open-ended questions to gauge the client's perception. If the client exhibits psychotic thoughts, confusion, or cannot organize their thoughts, immediately switch to direct, closed-ended questions focusing on one specific behavior at a time. Phrasing matters: ask "What types of discipline do you use?" rather than "How often do you physically punish your child?" to prevent defensive dishonesty. Family Input: Obtaining input from family is valuable, but the client must give permission. The nurse should always try to assess the client in private if abuse or intimidation is suspected. The 9 Must-Know Assessment Categories (The Organizing Framework) Nurses must systematically evaluate these nine areas to guide clinical judgment: History: Includes age, developmental stage, cultural beliefs, and family history. A family history of suicide, alcohol use disorder, or bipolar disorder represents a major safety risk factor. General Appearance & Motor Behavior: Observe hygiene, posture, eye contact, speech, and any unusual mannerisms. Mood & Affect: Assess the client's internal emotional state (mood) and outward facial expressions (affect). Thought Process & Content: Evaluate what they think (content) and how they think (process). This is where the nurse must systematically screen for dangerous cues like self-harm or suicidal urges. Sensorium & Intellectual Processes: Assess orientation, memory, confusion, concentration, abstract thinking, and abnormal sensory experiences. Judgment & Insight: Determine the client's decision-making ability (judgment) and their understanding of their own part in their current situation (insight). Self-Concept: Evaluate the client's personal view of their physical self and attributes. Roles & Relationships: Assess current life roles, relationship satisfaction, and their external support systems. Physiological & Self-Care: A crucial area focusing on sleep patterns, eating habits, medication adherence, and the client's ability to independently perform activities of daily living (ADLs).

MH | Grief and Loss

Core Concepts of Loss and Grieving Grief is the subjective emotional response to loss, while grieving (bereavement) is the process of experiencing it, and mourning is the outward, culturally defined expression. Losses fundamentally disrupt Maslow’s hierarchy of human needs, threatening physiological integrity, safety, security, self-esteem, and self-actualization. The grieving process is highly dynamic and unique to each individual; it is never an orderly progression. Major Frameworks of Grieving Nurses utilize several key theories to understand the grief process: Kübler-Ross: Denial, anger, bargaining, depression, and acceptance. Bowlby: Numbness, emotional yearning, cognitive disorganization, and reorganization. Engel: Shock/disbelief, developing awareness, restitution, resolution, and recovery. Horowitz: Outcry, denial/intrusion, working through, and completion. The Five Dimensions of Grieving Effective nursing requires a holistic assessment of five human responses: Cognitive: Disruption of beliefs, questioning the loss to make sense of it, and carrying on internal dialogues to keep the lost one present. Emotional: Predominantly anger, sadness, anxiety, guilt, despair, and intense loneliness. Spiritual: Deep spiritual suffering, anger with God, or conversely, finding comfort and meaning through religious belief systems. Behavioral: Numbness, uncontrollable crying, irritability, searching behaviors, and potentially maladaptive responses like substance use or suicide attempts. Physiological: Insomnia, headaches, impaired appetite, weight loss, lack of energy, and profound changes in the immune and endocrine systems. High-Risk Types of Grief Disenfranchised Grief: Occurs when a loss cannot be openly acknowledged or socially supported. Examples include stigmatized deaths (execution), unacknowledged losses (pets, prenatal death, abortions), non-kin relationships, or grief experienced by healthcare workers. Complicated Grieving: A prolonged, intensely persistent response that interferes with daily life. Risk factors include low self-esteem, prior psychiatric disorders, ambivalent attachments, and sudden, violent, or multiple deaths. Hospital visitation restrictions heavily increase susceptibility to complicated grief. Nursing Assessment and Interventions Nurses must carefully evaluate three critical factors: adequate perception of the loss, adequate situational support, and adequate coping behaviors. Priority Safety Actions: Assess for suicidal ideation, self-harm risk, and severe depression. Key Interventions: Establish a psychologically safe environment using an attentive presence and active listening. Support adaptive denial, allowing the client to gradually adjust to the reality of the loss. Encourage the client to express all emotions without placation, review past coping strengths, and care for physical needs. Refer clients to Cognitive-Behavioral Grief Therapy (CBGT) for complicated grief. Nurses must also maintain self-awareness regarding personal loss to remain fully therapeutic.

MH | Anger and Hostility

Core Concepts & Etiology Anger is a normal human emotion, but inappropriate expression leads to hostility (verbal intimidation) and physical aggression. Biologically, aggression is linked to low serotonin, elevated dopamine and norepinephrine, and limbic system damage. High-risk conditions include schizophrenia (especially with command hallucinations), bipolar disorder, substance intoxication, dementia, and personality disorders. "Acting out" is an immature defense mechanism where clients use physical actions rather than words to cope with feelings of powerlessness. The 5-Phase Aggression Cycle & Interventions Mastering this cycle is vital for clinical safety. Triggering: The client exhibits restlessness, pacing, anxiety, and a loud voice. Action: Approach calmly, convey empathy, encourage the verbal expression of feelings, offer PRN medications, and suggest moving to a quiet area. Escalation: Behavior rapidly escalates (yelling, threatening, clenched fists). Action: Use a directive approach with a calm, firm voice. Direct the client to take a time-out, offer PRNs again, and use a "show of force" (4-6 staff members in sight) to indicate that staff will maintain control. Crisis: The client completely loses physical control (hitting, kicking, throwing objects). Action: Intervene physically for safety in a matter-of-fact manner with no bargaining. Use seclusion or restraints with 4-6 trained staff, protect the head, and quickly obtain a provider's order for emergency intramuscular (IM) medications. Recovery: The client regains control and physically relaxes. Action: Encourage the client to discuss their triggers, assist them in relaxing, assess all staff for injuries, and conduct a mandatory staff debriefing. Postcrisis: The client returns to baseline, often displaying remorse or crying. Action: Remove restraints based on behavioral criteria, discuss the event rationally without lecturing, and reintegrate the client into the unit milieu. High-Yield Medications Treating the underlying psychiatric disorder is the primary way to prevent aggression. Acute Agitation: A combination of haloperidol (Haldol) and lorazepam (Ativan) quickly decreases severe agitation and psychotic symptoms. Lorazepam alone is preferred if the agitated patient is not psychotic. Long-Term Management: Lithium treats bipolar aggression. Anticonvulsants (carbamazepine, valproate) manage aggression in dementia, psychosis, and personality disorders. Atypical antipsychotics (clozapine, risperidone) are also highly effective. Always monitor for extrapyramidal side effects, which are swiftly treated with benztropine (Cogentin). Milieu Management & Safety A structured environment with planned activities and consistent 1-on-1 interactions minimizes boredom and prevents aggression. The absolute best predictor of future violence is a prior history of violent behavior. Maintain a safe distance during interactions—potentially violent patients require a body space zone up to four times larger than normal—and never trap the client. Finally, workplace safety requires a code of conduct with zero tolerance for lateral violence (staff bullying), per JCAHO standards.

MH | Abuse and Violence

1. Violent Families Family violence (intimate partner, child, elder) is characterized by social isolation, abuse of power/control, substance use (diminishes inhibitions but doesn't cause abuse), and the intergenerational transmission process (violence is a learned behavior). 2. Intimate Partner Violence (IPV) The abuser often displays low self-esteem and views their partner as property. The abused partner frequently stays due to financial dependency and fear. Crucially, the risk of homicide is highest when the victim attempts to leave. Cycle of Violence: Tension-building, a violent episode, and a honeymoon period (remorse). Over time, the honeymoon phase vanishes. Nursing Priorities: Always screen for abuse by asking clients privately, "Do you feel safe?". Do's/Don'ts: Do believe the client and help build a safety plan. Don't tell them to leave or recommend couples' counseling. 3. Child Abuse & Neglect Child maltreatment includes physical, sexual, and psychological abuse, but neglect is the most prevalent. Red Flags: Treatment delays, stories inconsistent with the injury (e.g., a 2-month-old rolling off a couch), and recognizable injury shapes (cigarette burns, stocking/glove scalds). Nursing Priorities: Nurses are mandatory reporters in all 50 states. You do not need to be certain; simply document and report. Do not interrogate the child yourself. 4. Elder Abuse Typically perpetrated by a caregiver. It involves physical, financial, psychosocial, or neglectful abuse. Abuse may develop gradually from caregiver burnout or intentionally for financial gain. Red Flags: Unpaid bills despite having funds, poor hygiene, and caregiver refusal to let the nurse speak to the patient alone. Reporting laws vary by state. 5. Rape & Sexual Assault Rape is legally defined as penetration without consent. It is not a sexual crime; it is an exertion of power, control, and punishment. Assessment: Preserve physical evidence. The exam must occur before the client showers, brushes teeth, douches, or changes clothes. Interventions: Restore the client's sense of control. Allow them to make decisions about their care and whether to press charges. Provide STD and pregnancy prophylaxis. 6. Communication & Community Violence Manage your own feelings of horror and never victim-blame. Say, "The abuse is not your fault". Help clients transition from "victims" to empowered "survivors". In communities, recognize that bullying and ostracism carry heavy risks for depression and youth suicide.

MH | Trauma and Stress Related Disorders

1. Must-Know Diagnoses & Timeframes Acute Stress Disorder (ASD): Develops after a traumatic event; symptoms (reexperiencing, avoidance, hyperarousal) last 3 days to 4 weeks. Posttraumatic Stress Disorder (PTSD): Symptoms can be delayed and last >1 month. It is chronic, with symptoms often worsening during stressful periods. Adjustment Disorder: Reaction to stressful life events (e.g., financial, work) causing out-of-proportion difficulty coping. Successful adjustment or resolution occurs within 6 months. Dissociative Disorders: Subconscious defense mechanisms protecting the emotional self from horrific trauma. Includes Dissociative Amnesia, Dissociative Identity Disorder, and Depersonalization/Derealization. 2. PTSD Core Symptoms & Findings Intrusion: Reliving trauma via flashbacks, nightmares, and recurrent intrusive thoughts. In children, this may manifest as repetitive play expressing trauma themes. Avoidance: Avoiding people, places, or stimuli associated with the trauma. Negative Cognition/Mood: Guilt, self-blame, detachment, and an inability to experience positive emotions. Hyperarousal: Insomnia, hypervigilance, irritability, and an exaggerated startle response. 3. Priority Nursing Assessments & Red Flags Safety First: The absolute priority is assessing for suicide risk and self-mutilation. Comorbidities: High risk for substance/alcohol use disorders (often used to self-medicate or blot out memories) and severe depression. Behavioral Red Flags: Flashbacks and dissociative episodes where the patient completely loses touch with present reality. 4. Must-Know Nursing Interventions Grounding Techniques: The top priority during a flashback or dissociation. Use sensory input to reorient the patient to the present (e.g., "Do you feel your feet on the floor?", "Can you see me?"). Physical Safety: NEVER grab or force a patient to move during a flashback; they may strike out defensively. Instead, ask them to change positions or walk to dispel the episode. Use supportive touch only if the patient previously consented. Therapeutic Communication: Validate feelings ("I know this is frightening, but you are safe now") and reorient by stating your name, the date, and location. Empowerment: Refer to the patient as a "survivor" rather than a "victim" to promote self-esteem, and help them identify a physical "safe place" to go when experiencing destructive thoughts. 5. Must-Know Medications & Therapies First-Line Meds: SSRIs (fluoxetine, paroxetine, sertraline) and SNRIs (venlafaxine) are the most effective. Targeted Meds: The atypical antipsychotic risperidone effectively targets hyperarousal. Benzodiazepines are widely used clinically but lack evidence of efficacy. Therapies: Outpatient therapy is primary. Modalities include Exposure Therapy (facing feared situations), Cognitive Processing Therapy (addressing guilt/self-blame), and Adaptive Disclosure (short-term CBT developed for the military).

MH | Anxiety Disorders

1. The Four Levels of Anxiety & Priorities Identifying the anxiety level dictates the correct nursing intervention. Mild: Senses sharpen; learning capacity increases. Action: This is the optimal time for client teaching. Moderate: Perceptual field narrows, but the client follows direction with assistance. Action: Use short, simple sentences and redirect the client to the task. Severe: Problem-solving is impossible; physical symptoms like tachycardia escalate. Action: Do not attempt teaching; lower the anxiety first and remain with the client. Panic: The client loses rational thought, cannot perceive danger, and exhibits fight, flight, or freeze responses. Action: Safety is the absolute priority. Remain with the client, move them to a small, quiet, non-stimulating environment, and use a calm voice. 2. High-Yield Disorders Panic Disorder: Episodes of intense fear lasting 15 to 30 minutes, often mimicking a heart attack (palpitations, chest pain, shortness of breath). Priority: Ensure privacy, guide deep breathing, and reassure the client they are safe. Long-term management uses cognitive behavioral therapy (CBT), positive reframing, and "decatastrophizing" to realistically appraise fears. Phobias: Illogical, intense fears of objects or situations. Agoraphobia (fear of places where panic attacks occur) often leads to homebound behavior. Treated via systematic desensitization (gradual exposure) or flooding. GAD: Excessive worry occurring at least 50% of the time for 6 months or more. 3. Neurobiology & Pharmacology Anxiety involves dysfunction of GABA, the body's primary inhibitory neurotransmitter. Benzodiazepines (Lorazepam, Alprazolam): Provide rapid relief for acute anxiety. Safety Red Flags: High potential for misuse and dependence. Use short-term (4-6 weeks), never stop abruptly, and avoid alcohol. They increase fall and fracture risks in older adults. Buspirone: Used for GAD with a very slow onset of action. SSRIs: Preferred class for older adults and long-term anxiety management. 4. Communication & General Principles Never force an anxious client to make choices. As anxiety subsides, use open-ended communication to explore triggers. Teach relaxation techniques only when the client is calm. Emphasize that the goal is effective management of stress, not total elimination of anxiety. Nurses must also monitor their own anxiety, as it is easily transmitted to clients interpersonally.

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