Chapter 67-72 Med surg

As anxiety is uneasiness without a readily identifiable cause and fear is a response to a known entity, there are many places which evoke an anxious or fearful response in people without anxiety disorders. Which of the following is not such a place?

bed

Smoking cessation programs are most successful when they include which components? Select all that apply.

counseling and behavior modification pharmacologic therapy

The nurse is assessing a client with a history of alcohol abuse. Which of the following is the most common defense mechanism used by a client diagnosed with a substance use problem?

denial

Which condition is most commonly found in a client who chronically abuses alcohol?

enlarged livr

A client has been diagnosed with posttraumatic stress disorder (PTSD). Which of the following statements best describe hallmark symptoms associated with PTSD:

flashbacks, recurring dreams, and numbness

A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

ptsd

The nurse is assessing a client with early signs of dementia. The nurse asks the client what he ate for breakfast that morning. The purpose of this question is to determine which of the following?

recent memory

Which neurotransmitter is thought to be responsible for depression?

serotonin

A nurse is caring for a client with social phobia. Which statement is most accurate regarding clients with social phobia?

they avoid social situations

A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

tolorance

A client is taking disulfiram and begins drinking a beer. What effect will be produced from the combination of alcohol and disulfiram?

vomiting

Which of the following instructions should a nurse give to clients with opiate dependency who take methadone?

wear medic alert tag

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which of the following is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice."

One week ago, the client was prescribed Buspirone (Buspar) for anxiety. The client phones the office and reports the medication has not eliminated the symptoms. Which is the best response by the nurse?

"It may take up to 4 weeks for full therapeutic response."

A client with mania is demonstrating hypersexual behavior: blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which of the following interventions is indicated at this time?

"Let's go to the conference room and talk for a while."

Which activities would be reasonable to teach a client who is prone to moderate to severe anxiety? Select all that apply.

*Breathe slowly and deeply in through the nose and out through the mouth. *Progressively relax groups of muscles from the toes to the head. *Repeat positive statements such as "I am in control," "I am safe," "I am relaxed," "I am competent."

Situations that may induce social phobia include:

-situations where one must perform in front of others. -eating with others in a restaurant. -attending a party where some attendees may be strangers.

Building trust is especially critical to developing a therapeutic relationship with an anxious client. Which of the following interventions contributes to this trust?

Be available and attentive to the client's requirements.

Which action by a client with stable schizophrenia is most important for preventing relapse?

Consistently taking prescribed medications

A nurse is helping a client with a stress-related disorder to foster improved coping skills. Which of the following measures would the nurse be most likely to suggest?

Explore the coping strategies the client has found helpful in the past and encourage their continued use.

A war veteran is diagnosed with posttraumatic stress disorder (PTSD). Which of the following are symptoms of this disorder? Select all that apply.

Nightmares flashbacks

Persons experiencing panic-level anxiety may act impulsively and risk their safety. Which of the following interventions ensures the safety of clients with anxiety?

The nurse remains composed to help such persons reduce anxiety.

Which nursing consideration is most important when administering medications to a suicidal client?

View the inside of the mouth to make sure that all medications are swallowed.

Which actions would be considered obsessive-compulsive? Select all that apply.

cleaning something repetitively hoarding unneeded items counting money repetitively

After a long history of intravenous heroin use, a client has expressed willingness to stop using heroin. The nurse would expect the client to receive which medication to decrease the severity of withdrawal?

methadone

Which assessment should a nurse initially perform for a client with schizophrenia?

mini-mental state exam

Understanding the definition of eating disorders is important in communicating facts while managing these conditions. Which is not an eating disorder?

obesity

Older adults should be given the lowest dosage of psychotropic drugs because:

of the potential for increased adverse reactions and toxicity.

As a nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?

"I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch."

A client has lost her job and is getting divorced. She comes to the clinic with an infection. During discussion, the client asks the nurse if stress might have caused the illness. Which of the following is the best response by the nurse?

"Stress can lower the numbers of white blood cells, which are the immune system's disease fighters."

Psychotherapy involves talking with a psychiatrist, psychologist, clinical nurse specialist, or mental health counselor. Which types of therapy may be used with clients with anxiety disorders. Select all that apply.

-behavioral therapy -cognitive theraypy

A nurse is providing a community seminar about eating disorders. Which age group would the nurse be most likely to target because of their increased risk?

12-25

What is the average number of calories an adult should consume per day to maintain a healthy weight?

1500-2500

There are several elements of teaching for clients with overeating syndromes and the families of these clients. Select all that apply.

Avoid nonprescription diet pills. Strict dieting or fasting is the leading cause of binging. Attend Overeaters Anonymous meetings`

An adolescent client is being admitted to the psychiatric unit for treatment of an eating disorder. Her admission interview reveals a history of recurrent episodes of binge eating and self-induced vomiting. The nurse recognizes these as symptoms of what disease?

Bulimia nervosa

Which of the following observations is helpful in determining a client's mood? Select all that apply.

Client appearance Body language Speech Energy level

A nurse is assisting with a comprehensive history and physical examination of a client with a suspected eating disorder. Which of the following signs and symptoms would the nurse recognize as consistent with anorexia nervosa? Select all that apply.

Decrease of 25% in body weight since last measurement Weight is 75% or less of normal Amenorrhea

A client is not dealing well with the diagnosis of cancer. She feels she is "so alone." Which intervention would be most appropriate for this client?

Educate the client on the availability of support groups for clients with cancer.

As a nurse planning care for a client with paranoid delusions, which of the following will be the priority goal?

Establishing trust.

An older adult client is admitted to the medical division after a fall. At home he is taking amitriptyline 25 mg three times per day. What adverse effect could be related to the patient's fall?

Orthostatic hypotension

The nurse is performing a history and physical examination on a client with chronic alcoholism. Which of the following conditions may be attributable to the client's history of alcohol abuse?

Pancreatitis Elevated liver enzymes Esophagitis

When planning care for a client newly diagnosed with Alzheimer's disease, the nurse should focus on:

Providing a safe, structured environment

A client arrives at the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following concerns takes highest priority in planning your nursing interventions?

Risk for injury.

A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Risk for self-directed violence related to depression

A 65-year-old client seeks crisis intervention in a community senior citizen center. She states she has very few financial resources, and her children never call or visit. She is sobbing and states, "I can't take it anymore. My life is so lonely and hard. I am living too long and shouldn't be here anymore." What is the most important assessment data for the nurse to further assess?

The meaning of the statement "I cannot take it anymore."

The nurse is assisting a client who is experiencing withdrawal from alcohol. Which manifestations would the nurse expect to see in this client? Select all that apply.

Tremors Hypertension Hallucinations

The client, who has recently stopped smoking, is agitated and complaining of a headache. The nurse would interpret this as which of the following?

Withdrawal

During which phase of the general adaptation syndrome is the "fight or flight" response activated?

alarm

What are the primary components of medical management for anorexia nervosa? Select all that apply.

all answers are correct nutritional therapy drug therapy psychotherapy family counseling

A client is being assessed for anorexia. A BMI of which of the following would be indicative of anorexia?

less than 16