Pearson Week 4 – Flashcards
Unlock all answers in this set
Unlock answersquestion
A​ 5-year-old client scheduled for a tonsillectomy asks the nurse if the operation is going to hurt. What is the best response by the​ nurse?
answer
Yes, but we will give you medicine to stop the pain before it​ starts. (Nurses preparing children for surgery should be honest regarding expectations about postoperative pain and how the care team is ready to respond and treat pain. The nurse should acknowledge that there will be pain but also explain that medicine can be used to stop the pain before it starts. Denying the presence of pain is not an honest response. Saying that the pain will be less than the​ client's current sore throat does not address how pain will be managed. Responding that pain medication will be provided with a shot could cause the child alarm. )
question
The nurse identifies the postoperative client as being at an increased risk for impaired oxygenation. Which is the best nursing intervention to address this client​'s ​problem?
answer
Apply oxygen 2 liters by face mask as prescribed (For a client at risk of impaired​ oxygenation, applying oxygen 2 liters by face mask would be the appropriate intervention to implement. Providing an antibiotic as prescribed would be applicable if the client were at risk for an infection. Medicating for pain would address the problem of comfort. Providing platelets would be appropriate for perfusion or coagulation problems. )
question
The nurse measures the client​'s blood​ pressure, pulse, and capillary refill prior to sending the client to the operating room. Which concept related to perioperative care is the nurse​ implementing?
answer
Perfusion (The concept of perfusion is related to perioperative care. Nurses must be aware of the client​'s hemodynamic status and understand the guidelines for perfusion. The client​'s hemodynamic status is measured through blood​ pressure, pulse, and capillary refill. Measuring blood​ pressure, pulse, and capillary refill does not directly support the concepts of​ safety, quality​ control, or infection control.)
question
The nurse is conducting the preoperative assessment. The client reports having a cup of black coffee before arriving for the scheduled surgery. What should the nurse do with this​ information?
answer
Notify the surgeon (The nurse should notify the surgeon with the information if the client has had anything to eat or drink within 8 hours prior to​ surgery, because this increases the​ client's risk of aspiration. The surgical procedure will be​ cancelled, especially if the surgery is elective. The client should not be given the preoperative medication until the surgeon in notified of the fluid intake. The nurse needs to do more than document the information in the medical record. The client should have been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the hospital for the procedure. )
question
A preoperative client asks if blood products will be used during the procedure. Which laboratory values should the nurse explain are used to determine the client​'s need for blood​ products?
answer
Platelets Hematocrit Red blood cell count Hemoglobin (The diagnostic tests of​ platelets, hematocrit,​ hemoglobin, and red blood cell count are used to determine if a blood transfusion is needed during the surgical procedure. Prothrombin time is used to determine the client​'s risk for bleeding.)
question
What postoperative assessment would indicate to the nurse a change in a client​'s cardiovascular​ status?
answer
Capillary refill time greater than 3 seconds Pedal pulse​ non-palpable Dropping blood pressure (Changes in cardiovascular status affect blood​ pressure, pulses, and capillary refill. Dropping blood​ pressure, non-palpable pedal​ pulse, and capillary refill time greater than 3 seconds reflect a change in the cardiovascular status. An absent gag reflex indicates a change in a protective neurological reflex. Vomiting indicates a change in gastrointestinal status.)
question
The nurse is preparing a client for a surgical procedure to remove a portion of the transverse colon. Which priority actions should the nurse include to reduce the client​'s risk of developing a postoperative​ complication?
answer
Monitor blood pressure and heart rate Ensure aseptic technique is used for the procedure Monitor body temperature (Open procedures place the client at a higher risk for blood​ loss, hypothermia and surgical site infections​ (SSIs). The nurse should monitor body​ temperature, blood​ pressure, and heart rate and ensure aseptic technique is used for the procedure. Urine concentration is used to monitor for hypernatremia and hypovolemia. Muscle twitching is associated with hyponatremia.)
question
The circulating nurse is ensuring that a client is adequately positioned for surgery and determines that the procedure is going to take longer than 30 minutes to complete. What did the nurse assess to make this​ determination?
answer
Client is wearing sequential compression devices. (For procedures expected to last 30 minutes or​ longer, clients may be prescribed to wear sequential compression devices to reduce the risk of venous thromboembolism development from prolonged inactivity. The use of the lithotomy position does not determine the length of the surgical procedure. Placing pillows under the knees is a preventive action for the client in the supine position for a surgical procedure. Most clients receiving anesthesia will have oxygen saturation monitored during the surgical procedure. )
question
While preparing medications for a client scheduled for​ surgery, the nurse observes that medications are scheduled for 0800​ hours, analyzes the medication​ vial, and reviews the client​'s arm band. Which rights of medication administration is the nurse​ performing?
answer
Right client Your answer is correct. Right time Your answer is correct. Right medicatio
question
A​ 78-year-old client is scheduled for surgery to repair an abdominal aortic aneurysm. Which interventions should the nurse make a priority when planning this client​'s ​care?
answer
Preventing infection Promoting skin integrity Your answer is correct. Maintaining a normal body temperature Your answer is correct. Maximizing respiratory function (Lifespan considerations for an older client having surgery include maintaining skin​ integrity, preventing surgical​ infections, preventing the development of​ pneumonia, and maintaining a normal body temperature. Oral intake is not a specific lifespan consideration for an older client having surgery.)
question
The nurse provides postoperative discharge instructions to a client recovering from a lumbar laminectomy. Which client statement indicates that additional teaching is​ required?
answer
I can drive myself​ home. (Most clients recovering from​ surgery, anesthesia, and receiving medications for pain are not permitted to drive because of the effects of the medications. The diet is usually resumed as tolerated. Pain medication should be taken as prescribed. The surgical wound is either covered or held together with​ Steri-Strips, which will fall off naturally. )
question
A client is scheduled for total hip replacement surgery the next morning. What is the appropriate skin preparation for this​ client?
answer
Wash the area twice with chlorhexidine gluconate (Clients undergoing open class I surgical procedures below the chin should have two preoperative washes with chlorhexidine gluconate​ (CHG) before surgery. Hair at the surgical site should not be removed whenever possible. Betadine and alcohol are not considered appropriate solutions to cleanse the skin before this type of procedure. )
question
What preoperative data would cause the nurse to place a client at risk for surgical​ infection?
answer
Prescribed steroids for chronic lung disease Body mass index of 33.7 Fasting blood glucose level of 258​ mg/dL (Clients with an increased body mass index​ (BMI), who have​ diabetes, or who take​ immunosuppressants, are at a higher risk for acquiring a postoperative infection. Taking acetaminophen and having a history of H. pylori does not increase the risk for developing a postoperative infection. )
question
Which postoperative medication orders should the nurse expect to implement while a client is in the postanesthesia care​ unit?
answer
Antiemetic every 4 hours as needed Analgesic every 4 hours as needed Medication to reverse anesthesia (Interventions that may be appropriate for inclusion in the plan of care for the client during the postoperative phase include administering antiemetic and pain medications and medications to reverse anesthesia as prescribed. Antihypertensives can usually be started the next day in the morning. The antibiotic has to wait until the results of the wound culture are obtained. )
question
A client scheduled for surgery is asking questions about the​ procedure, and expresses concern about his​ family, should anything go wrong. Which nursing diagnoses should the nurse use to guide this client​'s ​care?
answer
Potential for anticipatory grieving Potential for enhanced knowledge related to the surgical process (Potential for anticipatory grieving is appropriate because the client is concerned about what would happen to his family should anything go wrong with the surgery. Potential for enhanced knowledge related to the surgical process is appropriate because the client is asking questions about the procedure and there is the opportunity to increase the​ client's knowledge. There is no evidence to support potential for ineffective​ coping, potential for​ self-esteem alterations, or potential for dysfunctional family processes. )
question
The intraoperative nurse is preparing a client to receive electrosurgery. What are priority nursing actions before this procedure is​ performed?
answer
Remove client​'s jewelry and eyeglasses Ensure​ tattoos, metal​ implants, and scars are not used for pad placement (When using​ electrosurgery, the nurse needs to ensure that the pads are not placed over metal​ implants, tattoos or scars and that all jewelry and eyeglasses are removed from the client. Strict aseptic technique is needed when an immobilizing device is being placed through the​ client's skin. A baseline skin assessment is completed before using a pneumatic tourniquet. Covering windows and reflective surfaces is done when a laser is being used. )
question
The nurse believes that a client with severe PTSD will benefit from​ cognitive-behavioral therapy​ (CBT). What can the nurse describe as the characteristics of​ CBT?
answer
Client can change unhealthy thoughts. Client can safely confront fears. Client can do CBT exercises. (In​ CBT, the client can safely confront​ fears, change unhealthy thoughts and do CBT exercises. It does not mean the client can discontinue medications or remove stressors.)
question
The school nurse is especially concerned about a specific​ first-grade student. What​ personality-related characteristic would the nurse identify as increasing the risk for development of an anxiety​ disorder?
answer
Shy student (Being shy increases the risk of a child developing an anxiety disorder.​ Weight, height, and nearsightedness are not personality characteristics.)
question
A​ first-year nursing student goes to the​ university's counseling services. The student hopes that anxiety levels experienced during test taking could be reduced. The nurse counselor asks the student about first thoughts when a test is announced. What kind of appraisal is the counselor having the student​ consider?
answer
Primary appraisal (Primary appraisal happens immediately upon knowledge of the​ stressor, the upcoming test. Secondary appraisal takes place after​ that, when deciding how to react. Cognitive appraisal is the combination of both primary and secondary appraisal. There is no model called​ "anxiety appraisal.)
question
The local​ woman's club has invited a public health nurse to give a seminar about mental health issues. The nurse begins by talking about the disorders that are more common among women than among men. Which disorders will the nurse​ list?
answer
Posttraumatic stress disorder​ (PTSD) Anxiety disorder (Anxiety disorder and posttraumatic stress disorder​ (PTSD) are more common among women than among men.​ Obsessive-compulsive disorder is equally common among men and women. Phobia strikes men twice as often as women. Insomnia is a​ symptom, not a disorder.)
question
A nurse therapist is assessing an older client. The client and the nurse are from different cultures. What situation could complicate the​ nurse's assessment of the​ client?
answer
​Client's physical illness ​Client's cognitive changes ​Client's normal, healthy cultural response (The​ client's physical​ illness, cognitive​ changes, and​ normal, healthy cultural response might complicate the assessment. The​ client's age difference or work experience should not complicate the assessment.)
question
The mental health nurse is working with a​ long-term client who has struggled through many​ issues, including homelessness. The client reports finding subsidized housing. The nurse​ responds, "You persisted until you found an apartment.​ Congratulations!" What kind of independent intervention is the nurse​ implementing?
answer
Identifying successes in life Reinforcing positive coping efforts (The nurse reinforced the​ client's positive coping efforts and identified success in life tasks. The nurse did not validate​ client's feelings, implement cognitive behavioral therapy​ (CBT) interventions, or identify strategies to meet​ client's goals.)
question
The​ client, a​ psychologist, is interested in the mental health clinic​ nurse's viewpoint about​ Maslow's hierarchy of needs. When it comes to prioritizing a choice to react to a​ stressor, what do both of them know about this​ model?
answer
Individuals might have their own priorities. (ndividuals might have their own priorities. Not everyone chooses to satisfy the same basic requirements first. Coping with stressors can be part of any​ level, and there is no most important level of need.)
question
The nurse in an endocrinology clinic is seeing a client who has both diabetes and hyperthyroidism. What clinical symptoms could the client have that would be similar to those of a client with​ anxiety?
answer
Nervousness Your answer is correct. Tachycardia (The clinical symptoms that a client with diabetes and hyperthyroidism has in common with a client with anxiety are tachycardia and nervousness. The client with anxiety could have obsessive​ thoughts, feelings of​ fear, and ritualized routines. Those symptoms would not arise as a result of diabetes or hyperthyroidism.)
question
The senior center audience clapped when the parish nurse talked about a​ "worry center" in the brain.​ "Makes sense to​ me," one senior commented out loud. What can the nurse tell them about how the​ "worry center" affects their risk for anxiety​ disorders?
answer
Hypersensitivity increases the risk of anxiety disorders. (Hypersensitivity of the​ "worry center" in the brain increases the risk of anxiety disorders. It is not a matter or​ perfusion, oxygenation, or hormone secretion.)
question
A group of nursing students studying for final exams is talking about ways to better deal with stressful events in life. One student​ suggested, "During finals​ week, we should avoid biogenic​ stressors." How could the students follow that​ advice?
answer
​Don't go outside into freezing temperatures. ​Don't smoke cigarettes. ​Don't drink fluids with caffeine in them. (Biogenic stressors directly trigger the stress​ response, without the individual needing to know about their presence. This is true of​ caffeine, nicotine, and extreme temperatures. The student staying up all night knows the effect of delayed​ sleep, and can choose to end a study session. Students can choose to worry about the test​ results, or can choose to be confident about the outcome.)
question
The mother and father of the client with agoraphobia have accompanied the client to family therapy. Now the nurse therapist wants to recommend an outside organization that they can all join to get more support. What is the most relevant resource for the nurse to​ recommend?
answer
NAMI (The most relevant resource is​ NAMI, the National Alliance on Mental Illness. The National Institute of Mental Health​ (NIMH), Alcoholics Anonymous​ (AA), and the American Association of Retired Persons abbreviation​ (AARP) are not as relevant to the​ client's needs.)
question
A geriatric nurse is working with an older client who is having side effects from medications for an anxiety disorder. The nurse wants to refer the client for​ psychotherapy, but the client is adamant and​ states, "I​ don't want to see a​ psychiatrist; that's for crazy​ people!" What reassurance can the nurse give the​ client?
answer
​"Therapists see many people who​ aren't crazy." This is the correct answer. ​"Therapy added to meds has more success than meds​ alone." ​"Other professionals offer therapy besides​ psychiatrists." Your answer is correct. ​"Therapy can help manage the symptoms of​ anxiety." (Other professionals offer therapy besides psychiatrists. Therapy added to meds has more success than meds alone. Therapy can help manage the symptoms of anxiety. Therapists see many people who​ aren't crazy. Therapy and meds are not an​ either-or situation; the client can continue taking meds.)
question
A public health nurse is working with a client complaining of multiple uncomfortable symptoms. Many laboratory tests have been ordered to rule out​ physical, rather than mental or​ emotional, causes. What roles can the nurse take to help this​ client?
answer
Collecting samples for testing Explaining the testing process Educating about the meaning of test results (The nurse can collect samples for​ testing, explain the testing​ process, and educate about the meaning of test results. The nurse cannot order further tests or cancel tests.)
question
The teenage client has attended a community workshop on handling stress. What statements by the teenager would show understanding of the material​ presented?
answer
If I anticipate failing a​ test, my body reacts as if I actually had failed​ it." ​"I can choose how I react to​ stress." ​"I have to learn to cope with the stress in my​ life." (Coping with stress is a learned skill. People can choose how they react to stress. The body reacts to anticipated stress the same as actual stress. Everyone does not react the same to the same stressful​ situation, and exercise does not trigger the stress response.)
question
The pediatric nurse welcomes the parents of a child adopted from an international agency. The child was orphaned after a border war and still has nightmares. What diagnosis could the pediatric nurse be prepared to explain to the​ family?
answer
Posttraumatic stress disorder​ (PTSD) (The nurse could be expected to explain a diagnosis of posttraumatic stress disorder​ (PTSD) to the family. That is a more likely diagnosis than anxiety​ disorder, phobia, or insomnia.)
question
A client with diabetes is in the hallway outside the operating room suite. The client voices being scared of the​ outcome, and reports being very stressed. What changes from earlier data about vital signs and blood sugar would the operating room nurse expect to​ find?
answer
Increased pulse Your answer is correct. Increased serum glucose Your answer is correct. Increased blood pressure (The nurse would expect to find increases in​ pulse, blood​ pressure, and serum​ glucose, as a result of stress. The nurse would not expect decreases in body temperature or respirations.)
question
The nurse is teaching a​ 25-year-old female client about taking a selective serotonin reuptake inhibitor​ (SSRI) for anxiety. Which information should the nurse include in the​ teaching?
answer
The medication takes a few weeks before achieving the full effects (The full effects of SSRIs occur a few weeks after starting​ treatment, not right away. SSRIs have fewer side effects than older antidepressants.​ Beta-blockers are used to prevent physical symptoms of​ anxiety, such as blushing and​ hyperventilation, and to treat heart conditions.)
question
The nurse is planning care for a client diagnosed with a severe anxiety disorder. Which problems are appropriate for the nurse to include in the plan of ​care?
answer
Impaired social interaction Your answer is correct. Risk for sleep pattern disturbance Risk for ineffective​ self-health management (When planning care for a client with a severe anxiety​ disorder, the nurse should include impaired social​ interaction, risk for sleep pattern​ disturbance, and risk for ineffective​ self-health management. Acute pain and disturbed body image are not appropriate problems to include in the plan of care for this client.)
question
The nurse is providing care to a client recently diagnosed with generalized anxiety disorder​ (GAD). The client​'s family asks the nurse how this could have occurred. Based on the client​'s ​history, which response is the most​ appropriate?
answer
A lupus diagnosis has been specifically linked to generalized anxiety disorder (The most appropriate response by the nurse regarding the client​'s risk factors for developing GAD is the history of lupus. A maternal history of​ depression, belonging to the upper socioeconomic​ class, and the recent job loss are not known risk factors for developing GAD.)
question
The nurse is providing education to a client diagnosed with generalized anxiety disorder. The client is prescribed alprazolam​ (Xanax) and scheduled to receive​ cognitive-behavioral therapy​ (CBT). The client asks the nurse why medication and therapy are both needed. Which response by the nurse is the most​ appropriate?
answer
Cognitivedashbehavioral therapy in combination with medication is most effective when dealing with an anxiety disorder. (The most appropriate statement from the nurse is to educate the client that therapy used in combination to medication is the most effective treatment method for anxiety disorders. Medication can be effective without therapy and is not known to lead to substance abuse if not accompanied with therapy. CBT does not use complementary treatment methods.​ Therefore, this statement is not appropriate.)
question
The nurse is planning home care for a client with panic disorder. What should the nurse include in this client​'s plan of ​care?
answer
Participation in massage and yoga Your answer is correct. Use of transcendental meditation This is the correct answer. Participation in cognitivedash behavioral therapy Your answer is correct. Use of antianxiety medications as prescribed (Use of antianxiety medications and participation in cognitivedash behavioral ​therapy, transcendental​ meditation, massage, and yoga are appropriate to include in the client​'s plan of care. While placing the client in a​ quiet, less stimulating environment may be necessary during an acute episode of​ panic, the nurse should encourage the client to participate in all aspects of treatment with the goal of pursuing normal activities.)
question
A client presents to the emergency department with bizarre​ behavior, muscular​ incoordination, incoherence, and terror. Which condition should the nurse suspect the client is​ experiencing?
answer
Panic disorder (Clinical manifestations of panic disorder include bizarre​ behavior, muscular​ incoordination, incoherence, and terror. Clients with generalized anxiety disorder present with intense tension and​ worry, startle​ easily, and may have​ fatigue, headache, digestive​ issues, and irritability. Clients with separation anxiety disorder have severe anxiety around separation from home and major attachment figures. Clients with moderate anxiety disorder experience reduced​ alertness, feelings of discomfort and irritability with​ others, increased​ restlessness, and perspiration.)
question
The nurse is completing the physical examination of a client experiencing symptoms of an anxiety disorder. Which information should the nurse​ collect?
answer
General assessment (During the physical examination of a client with symptoms of an anxiety​ disorder, the nurse needs to complete a general assessment. Medication​ regimen, current​ stressors, and use of alcohol are part of the client​'s psychosocial​ history, which is obtained when completing the health history.)
question
During a home​ visit, the nurse evaluates a client recovering from generalized anxiety disorder​ (GAD). Which observation indicates that additional client teaching is​ required?
answer
The client has withdrawn from cognitivedash behavioral therapy​ (CBT). (The most effective treatment strategy for most people with an anxiety disorder is CBT combined with​ medication, so the client​'s withdrawal from CBT indicates that more teaching is required. Taking medication as prescribed and participating in wellness activities indicates understanding of how to manage anxiety. Seeking​ full-time employment indicates the client is managing anxiety successfully.)
question
A family is staying in a disaster relief center as a result of a flood that destroyed their home. The nurse serving the shelter plans care for the mother of the family based on the nursing diagnosis of anxiety. Which assessment finding would indicate that the client had achieved an appropriate goal for this​ condition?
answer
The client will report a reduction in stressful feelings. (The goal of reduced feelings of stress is related to the diagnosis. Although verbalizing coping​ strategies, remaining free from​ self-harm, and requesting assistance may be appropriate​ goals, they are not directly related to the​ client's anxiety.)
question
A client is brought into the emergency room after a fire has gutted the apartment he lives in. The physical assessment reveals that the client has suffered no bodily injuries. Which are some other actions the nurse should​ take?
answer
Determine the client​'s thought processes Your answer is correct. Listen supportively for emotional reactions Your answer is correct. Identify coping strengths Your answer is correct. Develop a​ follow-up plan (A physical assessment is only part of the assessment procedure when a client has experienced a crisis. A client should not be discharged until the nurse has completed other activities including determining the client​'s thought​ processes, listening supportively for emotional​ reactions, identifying coping​ strengths, and developing a​ follow-up plan.)
question
A family comes to a homeless shelter after the father loses his job and their house goes into foreclosure. The father tells the nurse that he wants to work and get a place for his family to​ live, but he doesn​'t know what to do. Which referral is most appropriate for this​ client?
answer
A referral for social services (A social service referral could provide the client with some housing​ assistance, as well as possible job training or job placement. The client has not exhibited symptoms of a mental health condition or spiritual​ distress, nor indicated the need for medication.)
question
A nurse arrives right after the first responders on the scene of a town affected by a volcanic eruption. After providing triage and emergency​ treatment, which community assessment steps should the nurse quickly​ take?
answer
Identify community mental health services This is the correct answer. Assess living conditions and availability of basic resources Your answer is correct. Identify organizational​ resources, such as disaster assistance Identify community support services (As one of the first civilians to provide​ help, the nurse should assess needs and identify basic resources. The nurse should also identify mental​ health, community​ support, and organizational support services. Referrals are a subsequent step in crisis services.)
question
An adult male client has been living in a shelter for 3 months after a tornado destroyed much of the town. The client is prescribed Isoniazid after a positive tuberculosis​ (TB) skin test and asks the nurse why it is important to take the​ medication, as he feels fine. How should the nurse respond to the​ client?
answer
His test indicates a latent form of TB and the medication will kill the bacteria and prevent the disease from becoming​ active." (The medication is important to prevent active​ TB, even without the presence of symptoms. Medications can be used after exposure to bacterial infections. The client​'s adherence will be improved by understanding the reasons for the prescription. His need for the medication was demonstrated by his positive skin​ test, not just by his residence in the shelter.)
question
The nurse is providing care to a client who is brought into the emergency department after being raped. Which questions can the nurse ask to help determine the client​'s social​ support?
answer
Is there someone you would like me to ​call? Who do you know that you think would be most helpful to you ​now? Do you have someone you would like to stay ​with? (The nurse should ask questions that identify the client​'s preferred supports and the type and availability of the support they might provide. An identified best friend may not be a preferred support. Parents may not be a preferred support for adults.)
question
A family is being assessed in a disaster relief center after being rescued from their home during a flood. The​ school-age client,​ Adam, does not answer any of the questions the nurse asks. The client sits hunched over with his thumb in his mouth during the entire interview. How should the nurse address this​ issue?
answer
The nurse should ask the parents whether or not this behavior was typical for Adam before the flood (Nurses should collaborate with the client​'s parents to establish baseline behaviors existing prior to the crisis or trauma. The nurse should not ignore behavioral indications of distress. The nurse should not intervene or make a referral without gathering sufficient information.)
question
A female adolescent client is brought into the emergency department​ (ED) after she was found wandering in the streets. She is unable to stop crying and is jumpy whenever anyone approaches. Which assessment findings indicate the client may have experienced a​ trauma?
answer
Intense emotional reactions Your answer is correct. Disorientation This is the correct answer. Hypervigilance (Clinical manifestations of trauma include​ disorientation, hypervigilance, and intense emotional reactions. Echolalia and perseveration are not clinical manifestations of trauma.)
question
During a health history​ interview, the nurse is concerned that an​ 8-year-old client is exhibiting signs of developing separation anxiety disorder. Which information from the interview supports this​ diagnosis?
answer
Overwhelming fear of being lost that has resulted in missing school (Symptoms powerful enough to interfere with daily life for at least 4 weeks and an overwhelming fear of being lost or having something bad happen to a loved one are related to development of separation anxiety disorder. A​ school-age child often becomes frightened when meeting new people. Excessive anxiety and worry for 6 months is a diagnostic criterion for generalized anxiety disorder. )
question
After reviewing multiple medical​ records, the nurse determines that which client is at highest risk for developing an anxiety​ disorder?
answer
The young adult female client who witnessed a car crash (Being female and witnessing a traumatic event are both risk factors for developing an anxiety​ disorder, so the young adult female client who witnessed a car crash is at highest risk. Although being female is a risk factor for an anxiety​ disorder, being married is not. Children with low socioeconomic status and adults with lower educational levels are also at higher risk.)
question
A client experiences a sudden onset of​ diaphoresis, mydriasis,​ palpitations, and immobility. A physical illness has been ruled out. Which type of medication should the nurse anticipate being prescribed for this​ client?
answer
Benzodiazepine (This client has symptoms of​ panic, so the nurse should expect an antianxiety​ medication, such as a​ benzodiazepine, to be prescribed. Benzodiazepines have few side​ effects, are felt within​ hours, and are the most commonly prescribed for clients experiencing panic.​ Beta-blockers prevent physical symptoms. SSRIs and azapirones may take several weeks to become effective.)
question
The nurse is planning care for a client who has been prescribed cognitivedashbehavioral therapy​ (CBT) and medication for an anxiety disorder. What complementary and alternative therapy could the nurse suggest for this ​client?
answer
Biofeedback Meditation Guided imagery Massage (Complementary and alternative medicine​ (CAM) has demonstrated effectiveness in easing symptoms of anxiety. CAM therapies include guided​ imagery, massage,​ biofeedback, and meditation. Norepinephrine is a​ neurotransmitter, not a therapy for anxiety disorders.)
question
While reviewing the goals in a​ client's plan of​ care, the client reports to the nurse that she wants to be taken off her antianxiety medication. Which findings indicate that the client is successfully meeting the identified goals and expected​ outcomes?
answer
"I sleep well at night​ now." Your answer is correct. ​"I feel​ good, not worried or​ anxious, most​ days." This is the correct answer. ​"I am taking a yoga class and a cooking​ class." ​"I use what I learned in therapy to calm myself down when I start feeling​ anxious." (Expected outcomes for clients who succeed in resolving anxiety disorders include​ self-moderation of the anxiety​ response, demonstrating new or improved coping​ measures, and reporting diminished anxiety. Missing work may indicate occupational​ impairment, which could be the result of the​ client's anxiety disorder.)
question
During a home​ visit, the nurse evaluates an older adult client who has been prescribed medication for diabetes mellitus and generalized anxiety disorder​ (GAD). Which statement by the client indicates that a modification to the plan of care may be​ required?
answer
"I had my wife prepare my medications when she was​ alive." (The statement about the​ client's wife giving him his medications may indicate that the client is not currently taking them as prescribed. The nurse needs to modify the plan of care to ensure that the client takes his prescribed medications.​ Cognitive-behavioral therapy combined with pharmacotherapy is the most effective treatment strategy. Sleeping at night and having a headache do not indicate the need for modifying the plan of care.)
question
When assessing multiple​ clients, the nurse determines that which clients are at risk for developing generalized anxiety​ disorder?
answer
The client who reports excessive anxiety and worry about his​ job, relationship and finances for the past 6 months The client who has difficulty​ concentrating, sleep​ disturbance, and muscle tension Your answer is correct. The client who finds it hard to control the worry and exhibits poor hygiene (The​ DSM-5 diagnostic criteria for generalized anxiety disorder include excessive anxiety and worry occurring more days than not for at least 6​ months; client finds it hard to control the​ worry; the anxiety and worry are associated with difficulty​ concentrating, sleep​ disturbance, and muscle​ tension; the​ anxiety, work, or physical symptoms cause clinically significant distress or impairment in​ social, occupational, or other​ functioning; and the disturbance is not attributable to the physiological effects of a substance. The clients who report no significant impairment and who deny current stressors do not appear to be at risk.)
question
The nurse is caring for a client who is experiencing severe anxiety. Which intervention should the nurse include on the plan of​ care?
answer
Administering medications to the client as ordered (When a client is experiencing severe​ anxiety, the nurse needs to administer medications as prescribed. Isolating the client will prevent disturbance or threat to others. The nurse needs to provide a​ safe, quiet​ environment, but should not leave the client unattended. Walking a mile on a treadmill is not appropriate for this client at this time.)
question
An adult client is being assessed after a flood has destroyed her home. She tells the nurse that she realizes God is punishing her for the life she leads. Which member of the crisis counseling team should the nurse consider referring the client to​ see, based on the assessment​ findings?
answer
Minister or religious counselor (Spiritual distress may be part of a crisis response and consultation with a religious counselor may be helpful. Grief counselors work with those who have experienced the death of a loved one. A family therapist helps with family dysfunction. Law enforcement helps with crisis​ response, not crisis counseling.)
question
A client has been staying with his daughter and her family after he lost his home during a hurricane. The client reports to the nurse that he is unable to sleep in a strange environment. Which action should the nurse​ take?
answer
Refer the client for an evaluation for sleep medication. (Medication may help the client with his sleep problem. There is no indication that the client​'s sleep problem is related to his level of activity. Exercise before bedtime is contraindicated in sleep disturbances. There is no indication that lack of privacy is contributing to the client​'s sleep problem.)
question
A client is relocated to a shelter after losing her home in a flood. She tells the nurse that all the mementos of her life in the theater have been​ destroyed, and she doesn​'t open double quote see any reason to go on.close double quote Which nursing action is the priority for this​ client?
answer
Refer for a mental health evaluation (The client is at risk for​ self-harm due to her suicidal ideation. The priority action is to refer the client for a mental health evaluation. While a social services consult may be​ warranted, this is not the priority. Administering antianxiety or antidepressant medications is not the priority in this situation.)
question
An adult female​ client, the victim of a​ flood, is discussing her family​'s losses with a nurse at the disaster recovery center. The client tells the​ nurse, open double quote We​'ve been through troubles before and we​'ll get through this​ one, too.close double quote Which response to adversity does the nurse see the client​ exhibiting?
answer
Resilience (Resilience is a dynamic response to adversity that provides the individual with a buffer from a crisis and has been associated with optimism. Denial is a refusal to admit that something is real. Sublimation is channeling instinctual drives into an acceptable form. Rationalization is justifying questionable behaviors.)
question
A nurse is assessing the crisis response of a client who survived a hurricane that destroyed the family home. The nurse asks the client to describe her distress on a scale from 1 to​ 10, with 1 being no distress and 10 being unbearable distress. Which technique is the nurse using in order to make an accurate​ assessment?
answer
Scaling (Scaling helps assess the order of magnitude of an individual​'s experience. Estimation is a rough calculation.​ Inter-rater agreement compares the results of two or more of the observers at a point in time. A tensiometer measures the surface tension of a liquid.)
question
A​ nurse, providing emergency services at the site of a building​ collapse, asks a displaced resident whether or not he has any plans for food and shelter for the evening. The resident​ says, open double quote It​'s none of your business. I​'ll take care of myself the way I always do.close double quote What information about the resident does this response give the​ nurse?
answer
It provides some information about the resident​'s coping patterns. (The resident​'s limited response provides some information about his perception of how he copes most effectively. It does not guarantee that his method of coping will work in this situation. It is​ not, by​ itself, an indication of a mental health issue. The resident​'s personality is not a subject of the assessment process.)
question
An adult Native American​ man, whose home has just been destroyed by a​ wildfire, is being treated in an emergency center for first degree burns. The nurse suggests that the client might need an​ analgesic, but he refuses. Which action by the nurse is the most​ appropriate?
answer
The nurse should understand that the client​'s culture may have a different approach to addressing pain and ask whether the client would be willing to explain his experience. (When working with clients from a different​ culture, the nurse should be respectful of the clients​' ​ perspective, while providing the opportunity for clients to discuss their experiences and responses.​ Judgmental, authoritative, and punitive approaches are not appropr)
question
An adolescent client is brought to the nurse​'s office by the principal and school guidance counselor. The client is visibly high but is able to function. Which action by the nurse would be a successful resolution to this​ crisis?
answer
Referral to a drug treatment program (Successful resolution to a crisis intervention occurs when the client receives the assistance he​ needs, such as a drug treatment referral. The client does not show any evidence of needing hospitalization. School suspension is not part of the nurse​'s responsibility. Drug​ sales, not drug​ use, require police reports.)
question
The nurse is caring for a client with​ obsessive-compulsive disorder​ (OCD) . Which clinical manifestations would the nurse expect to see in this​ client?
answer
Signs of distress and increased anxiety Your answer is correct. Physical complaints such as irritated skin Your answer is correct. Repetitive actions or motions Your answer is correct. Intrusive thoughts (Repetitive behaviors are a hallmark sign of OCD. Physical complaints can be seen in patients who perform repetitive activities such as hand washing. Signs of distress or increased anxiety can be seen in clients when they feel compelled to complete rituals. The ritual is the client​'s way of resolving the anxiety. A happy and overly excited affect is not a clinical manifestation associated with OCD.)
question
The nurse teaches a client about medications used in the treatment of​ obsessive-compulsive disorder​ (OCD). Which client statement indicates appropriate understanding of the teaching​ session?
answer
I may only have to take medication for​ 1-2 years and gradually be weaned off.close double quote (Clients with a successful medication regimen may be on therapy for 1dash 2 years and then be tapered off the medication while observing for symptom exacerbation. Individual client response will determine whether the client needs to be on medications for​ short-term or​ long-term use. All medications have side effects and clients should be taught about the side effects. Medications are effective in the management of OCD.)
question
The nurse is providing care to a client with​ obsessive-compulsive disorder​ (OCD). Which interventions are appropriate for this​ client?
answer
Assist the client with developing new coping mechanisms. Your answer is correct. Encourage the client to verbalize his or her feelings. Your answer is correct. Include time in the daily routine to perform the ritual. (Verbalization of feelings will assist the client with reducing stress and anxiety. The client with OCD needs to learn new coping skills to manage the intrusive thoughts that lead to the performance of rituals. Allowing time in a client​'s daily schedule to perform the ritual will allow the client to complete the ritual and still manage daily activities. A loud environment is not recommended. Interrupting a client​'s ritual may lead to increased anxiety and is not​ recommended, unless it is harmful to the client.)
question
The nurse is conducting a nursing assessment for a client diagnosed with​ obsessive-compulsive disorder​ (OCD). Which findings are indicative of the repetitive acts associated with ​OCD?
answer
Constant hand washing The need to lock and unlock doors (Assessment findings that illustrate the repetitive acts associated with OCD include constant hand washing and the need to lock and unlock doors. The other findings would not support the repetitive acts associated with OCD.)
question
A client asks the nurse how​ cognitive-behavioral therapy will help her to manage her​ obsessive-compulsive disorder. Which response by the nurse is the most​ appropriate?
answer
It teaches techniques that will help you lower stress. (​Cognitive-behavioral therapy aims to teach the client adaptive coping skills that will lower the client​'s stress and anxiety. Increase in​ self-esteem may be a result of receiving the cognitive behavioral​ therapy, but it is not the goal for the client with OCD.​ Cognitive-behavioral therapy does not aim to change a client​'s belief system.​ Cognitive-behavioral therapy will assist the client with lessening feelings of shame and anxiety.)
question
The nurse is assessing the mental health of a female adult client who has been under stress at work. The client wants to wash her hands every 2 to 3 minutes and wipes the flat surface areas in the clinic with a paper towel while talking to the nurse. Which aspect of​ obsessive-compulsive disorder​ (OCD) is this client​ exhibiting?
answer
Repetitive behavior (Clients diagnosed with OCD repeat behaviors over a short period of time in the absence of the need to perform these behaviors. Visual and auditory hallucinations are seeing things that are not there and hearing things that are not​ there, respectively, not repeated behaviors. Illogical thinking involves thoughts and ideas running together in the thought​ process, not repeated behaviors.)
question
he nurse is educating a client diagnosed with​ obsessive-compulsive disorder​ (OCD) on the different therapies that are available for the disorder. Which therapies are appropriate for the nurse to include in the teaching​ session?
answer
Cognitive-behavioral therapy Antipsychotic medication (Cognitive-behavioral therapy is a recommended treatment for OCD to assist the client with learning new coping skills. While not a​ first-line treatment,​ antipsychotics, such as​ risperidone, may be used in the treatment of OCD when the client has not responded to selective serotonin reuptake inhibitors​ (SSRIs). No information is available on the effectiveness of herbal supplements in the treatment of OCD. Antihypertensive agents are not indicated in the treatment of OCD.)
question
The nurse educator is teaching a group of students about​ obsessive-compulsive disorder​ (OCD). Which statement will the educator include in the teaching session regarding​ OCD?
answer
Children who have had a streptococcal infection may be at risk of developing the disorder. (Children with previous streptococcal infections are at risk for developing OCD. Clinical manifestations of OCD typically occur in children and young adults. Diagnosis of OCD is difficult due to the variations in clinical presentation. Brain imaging in clients with OCD is abnormal.)
question
The nurse is providing education to a client diagnosed with a phobia. Which suggestion by the nurse is appropriate regarding the use of physical exercise as a treatment​ option?
answer
Exercise releases​ endorphins, which will improve your mood and decrease anxiety.close double quote (Physical exercise has been known to release​ endorphins, which improve mood and decrease anxiety. While physical activity may help the client sleep better at​ night, this is not why it is suggested for the treatment of phobias. Simply walking outside will not help alleviate the client​'s fears. Thought blocking is a cognitive technique that is appropriate for a client diagnosed with a​ phobia; it is not an example of a physical activity)
question
A nurse is conducting a​ follow-up assessment on a client in the clinic. The client​ states, open double quote I usually cannot leave my house at all but now I can leave at least once a day.close double quote This statement made by the client indicates the client has achieved which​ goal?
answer
The client will report decreased frequency of phobic episodes. (The​ client's report of being able to leave the house daily indicates that the client has achieved the goal of decreased frequency of phobic episodes. Leaving the house daily does not demonstrate relaxation​ techniques, participation in therapeutic​ treatment, and verbalization of healthy coping skills to use in response to fear)
question
The nurse is developing a plan of care for a client who is experiencing anxiety related to a phobic disorder. The client states she has extreme difficulty falling asleep at night. Which would be most appropriate for the nurse to include in the plan of care for this​ client?
answer
Educating the client on relaxation techniques (Educating the client on relaxation techniques would be the most appropriate for the nurse to include in the plan of care based on the client​'s statement. Deep breathing exercises and other relaxation techniques may assist the client in relaxation prior to attempting to sleep. The other interventions may all be helpful to the​ client, but are not as likely to assist with promoting sleep.)
question
The nurse is preparing an educational​ in-service for staff nurses regarding phobias. Which statement is appropriate for the nurse to include in the
answer
Women are more likely to develop a phobia than men. (The nurse would include the statement that women are more likely to develop phobias when compared to men. While neurotransmitters are thought to be involved in the development of​ phobias, there is no indication that phobias are caused by a decrease in norepinephrine. Phobias are more likely to be diagnosed during adolescence and early adulthood. Phobias tend to run in​ families; meaning clients have a higher risk for developing a phobia if someone in their immediate family is diagnosed with this disorder.)
question
A client diagnosed with a mild social phobia would like to try a treatment method that does not require pills or weekly appointments. Which statement by the nurse is appropriate when educating this​ client?
answer
open double quote Certain lifestyle​ choices, such as decreasing caffeine​ intake, may be helpful for you.close double quote (There are certain lifestyle choices that the client can be educated about that have been effective to decrease the anxiety associated with certain phobias. One of these lifestyle choices is decreasing caffeine intake. Implosion therapy is an approach reserved for severe phobias exposing the client to the fear. Telling a client that they do not need to see a healthcare provider for this is inappropriate. )
question
The nurse is caring for a client diagnosed with arachnophobia who is prescribed systematic desensitization therapy. After providing education on this type of​ therapy, which statement by the client indicates the need for further​ education?
answer
I am going to be placed in a room with spiders during my first session (he client would require more education after stating that it was an expectation to be placed in a room with spiders during the first session. This portion of the therapy does not occur until near the end of treatment. All other statements indicate appropriate understanding of the teaching provided by the nurse.)
question
The nursing instructor has just finished educating a group of nursing students on the risk factors associated with the development of phobias. Which statement made by a student nurse would indicate the need for further​ education?
answer
Individuals are at lower risk of developing a phobia if their mom has the phobia(The​ statement, open double quote Individuals are at lower risk of developing a phobia if their mom has the ​phobia, indicates the need for further education because individuals are actually at a higher risk of developing a phobia if an immediate family member has a phobia disorder.)
question
The nurse is assessing a client who reports anxiety associated with a previously diagnosed social anxiety disorder. What signs and symptoms would the nurse expect to​ assess?
answer
Mumbling speech Excessive sweating Gastrointestinal distress (Excessive​ sweating, mumbling​ speech, and gastrointestinal distress are all physical symptoms associated with social anxiety disorder. Lethargy and​ warm, dry skin are not associated with social anxiety disorder.)
question
The nurse is providing care for a client diagnosed with posttraumatic stress disorder​ (PTSD). The client​'s family has asked about nonpharmacologic therapies that may be appropriate. Which therapies will the nurse mention when responding to this​ family?
answer
Eye movement desensitization and reprocessing therapy Your answer is correct. Acupuncture therapy Cognitive-behavioral therapy (CBT​ (cognitive behavioral​ therapy) and EMDR​ (eye movement desensitization and reprocessing​ therapy) are nonpharmacologic therapies used by interdisciplinary teams to treat posttraumatic stress disorder. Acupuncture therapy is a​ complementary, nonpharmacologic therapy that has been useful in the treatment of PTSD. SSRI​ (selective serotonin/noreprinephrine reuptake​ inhibitor) and atypical antipsychotic therapy are both pharmacologic therapies that may be used to treat PTSD.)
question
The nurse is preparing to complete a nursing assessment for a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which data will the nurse collect during the physical examination portion of the​ assessment?
answer
Pain rating (During the physical examination portion of the nursing​ assessment, the nurse would assess the​ client's pain rating using an appropriate pain scale. Alcohol​ use, current​ job, and type of trauma experienced would be assessed during the psychosocial health history portion of the nursing assessment.)
question
The nurse is providing care to a client diagnosed with posttraumatic stress disorder​ (PTSD). Which items in the client​'s health history place the client at risk for this​ disorder?
answer
Preexisting mental illness Witnessing the death of a friend Your answer is correct. Losing a job after a traumatic event. (Risk factors for developing PTSD include direct exposure to a traumatic​ event, losing a job after the​ event, and preexisting mental illness. Difficulty sleeping is a clinical manifestation of​ PTSD, not a risk factor. A concurrent diagnosis of diabetes mellitus is not a risk factor for PTSD.)
question
The nurse educator is teaching a group of students about posttraumatic stress disorder​ (PTSD). Which statements from the students regarding factors associated with the pathophysiology of PTSD indicate appropriate​ understanding?
answer
"Engaging in military​ combat" Your answer is correct. ​"Being taken hostage and​ tortured" ​"Going to​ prison" (For a diagnosis of​ PTSD, the client must have experienced direct exposure to the traumatic​ stressor, witnessed it in​ person, had indirect exposure​ (for example by learning that a close friend or relative was exposed to trauma such as violent or accidental​ death), or had repeated or extreme exposure to aversive details of the traumatic event​ (usually through professional​ duties, such as being a first​ responder). Nonprofessional exposure through electronic​ media, television,​ movies, or photographs does not qualify for a diagnosis of PTSD.)
question
The nurse is providing care to a​ client, diagnosed with posttraumatic stress disorder​ (PTSD), who is experiencing frequent nightmares. Which medication does the nurse anticipate will be prescribed for this​ client?
answer
Prazosin (e While​ Sertraline, paroxetine and risperidone are appropriate for a client diagnosed with​ PTSD, the only medication that has shown effectiveness in reducing nightmares associated with PTSD is​ prazosin, an antiadrenergic agent.)
question
The nurse is caring for a client who is diagnosed with posttraumatic stress disorder. Which goals and outcomes may be appropriate for the nurse to include in the client​'s plan of​ care?
answer
The client will report fewer or no nightmares. Your answer is correct. The client will talk about emotions that are associated with traumatic experiences with at least one counseling professional. The client will remain free of harm or injury to himself or others. (General examples of client goals and outcomes that may be appropriate for inclusion in the plan of care for the client with PTSD include the​ following: The client will remain free of harm or injury to himself or others. The client will articulate decreased feelings of anxiety. emotions that are associated with traumatic experiences with at least one counseling professional or other mental health care provider. The client will report fewer or no nightmares. The client will articulate awareness of stress reduction techniques that are not pharmacologic. Demonstrating comorbidity or avoidance are clinical manifestations of the​ disorder, not client goals and outcomes._
question
The student nurse has completed a care plan for a client diagnosed with posttraumatic stress disorder. Which intervention is not appropriate for the student to include in the plan of care for this​ client?
answer
Administer propranolol as ordered (The student nurse would not include administering anticonvulsants in the plan of care for this client. Propranolol is a beta blocker that is not a pharmacologic therapy for PTSD. All the other interventions are appropriate.)
question
The nurse is providing care to a client who is diagnosed with posttraumatic stress disorder​ (PTSD). Which factors could interfere with the nurse establishing trust during a therapeutic encounter with this​ client?
answer
Hypervigilance Depersonalization ​Irritability, aggressiveness (Clients with PTSD have experienced traumatization. They may be physically and emotionally isolated. They may be​ irritable, aggressive, emotionally​ numb, frightened, experiencing​ flashbacks, and on high physical and emotional alert during an appointment with the nurse. They may be reluctant to share their thoughts and feelings and should not be pressured to until they feel ready. These clinical manifestations of PTSD make establishing trust with the client a challenge for the nurse. Nightmares are a clinical manifestation of PTSD that does not take place during therapeutic encounters between the client and nurse. Ineffective coping is a problem that may be included in the nursing plan of care for a client with PTSD.)
question
The nurse teaches the family of a child recently diagnosed with​ obsessive-compulsive disorder​ (OCD) what to expect from their child. Which statement by the family indicates effective​ client/family teaching?
answer
I will allow additional time for breakfast in order for my son to complete his ritual.close double quote (Additional time will allow the client to complete the ritual and continue with other activities. Interrupting the client​'s ritual will only increase the client​'s stress and anxiety. A statement indicating that the son will never get better indicates the need for further education. Medication alone is often not effective in the treatment of OCD. A combination of​ cognitive-behavioral therapy and medication is recommended.)
question
At an inpatient​ facility, the client with obsessive compulsive disorder​ (OCD) counts the number of tiles on the floor each morning before going to breakfast. This ritual takes the client 30 minutes and the client always misses breakfast. Which interventions by the nurse can assist the client in arriving to breakfast prior to the meal​ ending?
answer
Allow additional time in the client​'s morning routine to include ritual before breakfast. Your answer is correct. Set limits on the amount of time the client performs the ritual. (Allowing additional time for the client to complete the ritual and setting limits on the amount of time the client is allowed to complete the ritual are therapeutic interventions for this client. Interrupting the client​'s ritual causes additional stress and anxiety and is not therapeutic. Cancelling the client​'s breakfast is not therapeutic. Placing the client in restraints is inappropriate.)
question
A client diagnosed with​ obsessive-compulsive disorder​ (OCD) tells the nurse that he has had feelings of apprehension that are alleviated through frequent hand washing. The​ client's hands are​ red, swollen, and the nurse notes several areas of excoriation. Based on the assessment​ findings, which nursing diagnosis is a priority for this​ client?
answer
Impaired skin integrity (The client who is exhibiting skin breakdown is experiencing the nursing diagnosis of impaired skin integrity. While the other nursing diagnoses are appropriate for a client with​ OCD, they are not a priority for this client.)
question
A client with​ obsessive-compulsive disorder​ (OCD) is admitted to an inpatient unit for treatment of the disorder. Which classification of medications can the nurse expect the healthcare provider to order as first line therapy for treatment of​ OCD?
answer
Selective serotonin reuptake inhibitors​ (SSRI) (SSRIs are the​ first-line therapy for clients with OCD. Oral hypoglycemics and anticonvulsant agents are not indicated for this disorder. Antipsychotics are used in the treatment of​ OCD, but are not considered first line therapy.)
question
A​ school-age male client checks and rechecks the locks on the doors of his home at least 15 times before leaving for school in the morning. The client​'s mother brings him to the healthcare provider​'s office today for a​ check-up. Which statement by the nurse is most appropriate in regard to the etiology of​ obsessive-compulsive disorder​ (OCD)?
answer
Twenty-five percent of all males with OCD experience symptoms prior to age 10. (Twenty-five percent of all males with OCD are diagnosed prior to the age of 10. Males and females are equally​ affected; however, the males are at an earlier age when the disease occurs. Manifestations of OCD are seen in​ children, adolescents, and young adults. Children with OCD have a​ 40% chance of experiencing remission by the time they reach adultho)
question
A client with​ obsessive-compulsive disorder​ (OCD) tells the nurses that he checks the locks to his house 10 times before leaving in the morning for work. The​ client's mother does not understand why her son does this. The nurse bases her response on which rationale for the​ behavior?
answer
Reduce anxiety (The only statement that is correct in this scenario is reducing anxiety. Clients with OCD perform rituals to control intrusive​ thoughts, not to check the safety of the​ home, to control​ others, or to call attention to themselves.)
question
The nurse is reviewing the health history of a client who will be seen later in the day. Which items place this client at risk for developing​ obsessive-compulsive disorder​ (OCD)?
answer
Sexual abuse as a child Your answer is correct. Death of the mother at a young age Domestic abuse (Items in the client​'s history that increase the risk of OCD include the death of the mother at a young​ age, domestic​ abuse, and sexual abuse as a child. A sister with depression and having a father who suffers from substance abuse are not risk factors for developing OCD.)
question
The nurse observes an adult client pacing the room and wringing his hands. The client checks the lock on the exam room door 12 times after the nurse enters the room. Which assessment questions would be appropriate when evaluating this ​client?
answer
Does this behavior interfere with your daily ​life?close double quote Your answer is correct. open double quote How old were you when you first started this ​behavior? (Appropriate questions for the nurse to include in the assessment of this client include asking the client when the behavior started and if it interferes with daily life. The other questions are not helpful in evaluating this client.)
question
The nurse is speaking to a client in the milieu area when the client​ states, open double quote I really hope that this therapy helps. I am not sure being shown pictures of spiders is going to help.close double quote The nurse is aware that which​ cognitive-behavioral technique is being​ implemented?
answer
Desensitization (The client​'s statement demonstrates participation in desensitization. Desensitization is the exposure to the situation causing the anxiety. Cognitive restructuring is the application of learned reframing or reinterpretation of the anxiety or fear. Reciprocal inhibition is a technique in which there is a stimulus that counteracts the undesired effect from the phobic stimulus. Cognitive inhibition is not a cognitive behavioral technique used in the treatment of clients with phobias. )
question
The nurse is providing care to a client diagnosed with a phobia. Which items will the nurse assess during the health history portion of the nursing assessment for this​ client?
answer
Type of phobia Your answer is correct. Drug sensitivities Allergies (Drug​ sensitivities, allergies, and the type of phobia are a part of the health history in an admission assessment for a client diagnosed with a social phobia. Physical signs and current level of anxiety are a part of the physical examination that occurs in an admission assessment for a client diagnosed with a phobia._)
question
The nurse is reviewing orders for a client admitted with a phobic disorder and notes the healthcare provider ordered the client to start on diazepam​ (Valium). Which information will the nurse include in the medication teaching for this​ client?
answer
It works promptly. This is the correct answer. It is usually ordered for short periods of time. It reduces​ anxiety, allowing participation in psychotherapy. Your answer is correct. It is a benzodiazepine. (Diazepam​ (Valium) is a benzodiazepine that works​ promptly, induces​ relaxation, alleviates emotional​ stress, and reduces​ anxiety, allowing the client to participate in psychotherapy.​ Furthermore, it is usually ordered​ short-term. Selective serotonin reuptake inhibitor​ (SSRI) are usually prescribed when the client needs a more​ long-term period of treatment.)
question
A nurse is admitting a client diagnosed with social anxiety disorder. Which items will the nurse include in the physical examination portion of this client​'s ​assessment?
answer
Nutritional status This is the correct answer. Behavior Your answer is correct. Vital signs (Vital​ signs, nutritional​ status, and behavior are a part of the physical examination in an admission assessment. Substance use and medications are a part of the health history in an admission assessment.)
question
The nurse is caring for a pediatric client and family in the emergency department. The​ client, an adolescent​ male, is admitted due to having difficulty breathing while on a field trip to the Empire State Building. The family states that the client experienced the same symptoms while standing on the balcony of their hotel​ room, which is on the 25th floor. Which phobia will the nurse provide education​ for, based on the assessment​ data?
answer
Acrophobia (The client is exhibiting symptoms of​ acrophobia, which is fear of heights. It would be appropriate for the nurse to educate the client and family about this phobia. Agoraphobia is characterized by anxiety associated with two or more of the following​ situations: being in enclosed​ spaces, being in open​ spaces, utilizing public​ transportation, being in a crowd or standing in a line of​ people, or being alone outside the home environment. Hematophobia is fear of blood. Nyctophobia is fear of darkness or nighttime.)
question
The nursing instructor is educating a group of students on the different types of phobias. After the​ presentation, which statement made by a student nurse indicates the need for further​ instruction?
answer
Agoraphobia is a fear of spiders.close double quote (Agoraphobia is not a fear of spiders but a fear of certain places and​ situations; arachnophobia is the fear of spiders and would require further education on the topic. All other statements indicate correct understanding of the information presented.)
question
The nurse is educating the client on relaxation strategies. Which are appropriate strategies to implement when promoting relaxation and rest at​ bedtime?
answer
Avoiding caffeine Your answer is correct. Encouraging deep breathing Avoiding nicotine Your answer is correct. Encouraging exercise (Avoiding​ nicotine, avoiding​ caffeine, encouraging deep​ breathing, and encouraging exercise are all appropriate strategies to promote relaxation. While encouraging exposure to the phobia may be beneficial to the​ client, it is not an appropriate strategy to implement to promote relaxation at bedtime.)
question
The nurse is teaching a client about food and beverage choices that may decrease anxiety and fear associated with phobias. Which statement indicates the need for further​ education?
answer
I can still enjoy an energy drink after my workout. (Energy drinks are known to have high amounts of caffeine which is discouraged for clients diagnosed with a phobia. This statement indicates the need for further education. All the other statements indicate the client has understood the teaching session.)
question
What would the nurse observe in the client with posttraumatic stress disorder PTSD who successfully achieves the identified client goals and​ outcomes?
answer
The client has fewer experiences of​ dissociation, negative thoughts. Your answer is correct. The client spends less time obsessively worrying. The client uses​ self-soothing techniques. (For the client with PTSD who successfully achieves the identified client goals and​ outcomes, examples of nursing observations during the evaluation phase may include​ that: the client has fewer experiences of​ flashbacks, dissociation, negative​ thoughts, and other clinical manifestations of​ PTSD; the client uses​ self-soothing techniques; and the client spends less time obsessively worrying and articulates more accurate predictions of events to come. Disrupted sleep at night would indicate the client​'s plan of care is not effective in treating impaired sleep patterns and would require a revised plan of care. Continued avoidance of reminders of the event would indicate the client​'s plan of care needs to be revised.)
question
A client is prescribed prazosin in the pharmacologic treatment of posttraumatic stress disorder​ (PTSD). The client asks how a blood pressure medication will help his symptoms. Which response by the nurse is the most​ appropriate?
answer
The medication has been found quite useful to reduce the nightmares associated with PTSD. (Prazosin is an​ anti-adrenergic agent that has been used to treat hypertension for many years. Recent research has found that this medication is useful in the treatment of the nightmares associated with PTSD. While the medication will reduce blood​ pressure, this is not the reason it is used for PTSD. It is not appropriate for the nurse to avoid answering the question and​ follow-up with the healthcare provider.)
question
The nurse is assessing a​ 5-year-old client who is diagnosed with posttraumatic stress disorder​ (PTSD). The child is accompanied by his parents. Which assessment question is most​ appropriate?
answer
open double quote Can you tell me what happens while you are asleep at ​night? (When assessing a child who may have​ PTSD, it is helpful to use direction questioning. For​ example, it is best to question the child as if there has been a change in his or her sleeping habits. Drawing picture can often cause the child to​ re-experience the trauma. And they might not recognize when they are angry or sad. This should be used with caution in children diagnosed with PTSD.)
question
The nurse is providing discharge teaching for a client diagnosed with posttraumatic stress disorder​ (PTSD). Which statement by the client indicates the need for further​ education?
answer
I will drink a few beers when I am anxious. (Using alcoholic beverages as a means of controlling anxiety indicates the need for further education. The other client statements indicate understanding of the discharge teaching provided by the nurse.)
question
The nurse is teaching the client and family about eye movement desensitization and reprocessing therapy​ (EMDR), which has been successful in the treatment of posttraumatic stress disorder. Which teaching points will the nurse include in the session with the client and​ family?
answer
External focus is on a different stimulus Reprocesses the trauma This is the correct answer. Effective nonpharmacologic therapy (The largest number of studies on psychotherapy for PTSD indicates that​ cognitive-behavioral treatments, as well as eye movement desensitization and reprocessing​ (EMDR), are the most effective therapies for PTSD. EMDR includes aspects of CBT and​ body-centered therapy. In this type of​ therapy, the client reprocesses the trauma by focusing internally on the traumatic event while focusing externally on a different stimulus. EMDR is a nonpharmacologic therapy that is used to treat​ PTSD, not a telehealth strategy. Telehealth is the delivery of​ health-related services and information via telecommunications technologies. Effective pharmacological therapy is not a consideration in eye movement desensitization and reprocessing therapy​ (EMDR). )
question
The community health nurse is preparing a presentation for posttraumatic stress disorder​ (PTSD) to a group of people whose spouses have just returned from an active war zone. Which etiologies for PTSD will the nurse include in the​ presentation?
answer
History of psychiatric disorders is common. Stressors can occur at any time or age of life. Traumatic events in childhood can create clinical symptoms that last into adulthood. (Exposure to a traumatic stressor can happen at any age or time of life. Traumatic stress in childhood can create effects that persist into adulthood. PTSD is more common among individuals with a history of psychiatric disorders. Women are more susceptible to the development of PTSD than men. The incidence of PTSD among veterans is especially high.)
question
The nurse is assessing a client diagnosed with posttraumatic stress disorder​ (PTSD). Which assessment findings support this client​'s ​diagnosis?
answer
Experience of frightening thoughts Your answer is correct. A frequent feeling of depersonalization Avoidance of​ trauma-related situations (​Depersonalization, avoidance of​ trauma-related situations, and frightening thoughts are all clinical manifestations of PTSD. Lack of social and psychological support and additional stressors that occur soon after the initial stressor are risk factors for developing​ PTSD, not clinical manifestations.)
question
The nurse is conducting a nursing assessment for a client diagnosed with posttraumatic stress disorder​ (PTSD). Which finding is the priority for this​ client?
answer
History of suicide attempts (A history of suicide attempts places this client at an increased risk of injury and would take priority. Having a history of traumatic brain injury is a risk factor for PTSD. While recently losing a job and a lack of social support can affect both the client​'s symptoms and​ recovery, a history of suicide attempts is the priority.)
