Exam 3

A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this client's problem? 1. Rates anxiety as 4 out of 10 by discharge. 2. States anxiety level has decreased by day one. 3. Accomplishes activities of daily living independently. 4. Demonstrates ability for adequate social functioning by day three.

1

By which biological mechanism does EMDR achieve its therapeutic effect? 1. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown. 2. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness. 3. EMDR achieves its therapeutic effect by causing an increase in memory access. 4. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.

1

Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)? 1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to "normal" daily events. 2. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to "normal" daily events. 3. Depressive symptoms occur in PTSD and not in AD. 4. Depressive symptoms occur in AD and not in PTSD.

1

A client diagnosed with an adjustment disorder says to the nurse, "Tell me about medications that will cure this problem." Which of the following are appropriate nursing responses? (Select all that apply.) 1. "Medications can interfere with your ability to find a more permanent problem solution." 2. "Medications may mask the real problem at the root of this diagnosis." 3. "Adjustment disorders are not commonly treated with medications." 4. "Psychoactive drugs carry the potential for physiological and psychological dependence." 5. "Psychoactive drugs will be prescribed only if your problems persist for more than three months."

1,2,3,4

A nurse is admitting a client who has been diagnosed with PTSD. Which of the following symptoms might the nurse expect to assess? (Select all that apply.) 1. Feelings of guilt that precipitate social isolation 2. Aggressive behavior that affects job performance 3. Relationship problems 4. High levels of anxiety 5. Escalating symptoms lasting less than one month

1,2,3,4

A nurse would recognize which of the following as the best predictors of PTSD in Vietnam veterans? (Select all that apply.) 1. The severity of the stressor 2. The degree of ego strength 3. The degree of psychosocial isolation in the recovery environment 4. The attitudes of society regarding the experience 5. The presence of preexisting psychopathology

1,3

A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ? 1. Encourage the journaling of feelings. 2. Assess for the stage of grief in which the client is fixed. 3. Provide community resources to address the client's concerns. 4. Encourage attending a grief therapy group.

2

A client has been extremely nervous ever since a person died as a result of the client's drunk driving. When assessing for the diagnosis of AD, within what time frame should the nurse expect the client to exhibit symptoms? 1. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within one year of the accident. 2. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within three months of the accident. 3. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within six months of the accident. 4. To meet the DSM-5 criteria for adjustment disorder, the client should exhibit symptoms within nine months of the accident.

2

A client receiving EMDR therapy says, "After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life." Which of the following nursing responses is most appropriate? 1. "I am thrilled that you have responded so rapidly to EMDR." 2. "To achieve lasting results, all eight phases of EMDR must be completed." 3. "If I were you, I would complete the EMDR and comply with doctor's orders." 4. "How do you feel about continuing the therapy?"

2

A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that learning has occurred? 1. "How clients perceive events and view the world affect their response to trauma." 2. "The psychic numbing in PTSD is a result of negative reinforcement." 3. "The individual becomes addicted to the trauma owing to an endogenous opioid response." 4. "Believing that the world is meaningful and controllable can protect an individual from PTSD."

2

After a teaching session about grief, a client says to the nurse, "I seem to be stuck in the anger stage of grieving over the loss of my son." How would the nurse assess this statement, and in what phase of the nursing process would this occur? 1. Assessment phase; nursing actions have been successful in achieving the objectives of care. 2. Evaluation phase; nursing actions have been successful in achieving the objectives of care. 3. Implementation phase; nursing actions have been successful in achieving the objectives of care. 4. Diagnosis phase; nursing actions have been successful in achieving the objectives of care.

2

A family asks the nurse why their son was diagnosed with PTSD and others in the accident were not. Which of the following information should the nurse offer? (Select all that apply.) 1. An individual's religious affiliation can affect response to trauma. 2. Responses are affected by how an individual handled previous trauma. 3. Protectiveness of family and friends can help an individual deal with trauma. 4. Control over the possibility of recurrence can affect the response to trauma. 5. The time in which the trauma occurred can affect the individual's response.

2,3,4,5

A client diagnosed with PTSD states, "Why did my doctor prescribe an antidepressant rather than an antianxiety drug for me?" Which of the following are the most appropriate nursing responses? (Select all that apply.) 1. "I'm not sure, because antianxiety drugs have been approved by the FDA for PTSD." 2. "Antidepressants are now considered first-line treatment choice for PTSD." 3. "Many people have adverse reactions to antianxiety drugs." 4. "Because of their addictive properties, antianxiety drugs are less desirable." 5. "There have been no controlled studies on the effect of antianxiety drugs on PTSD."

2,4,5

A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication? 1. Flat affect and anhedonia 2. Persistent anorexia and 10 lb weight loss in 3 weeks 3. Flashbacks of killing the enemy 4. Distant and guarded in relationships

3

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client's symptom? 1. Anxiety 2. Altered thought processes 3. Complicated grieving 4. Altered sensory perception

3

Both situational and intrapersonal factors most likely contribute to an individual's stress response. Which factor would a nurse categorize as intrapersonal? 1. Occupational opportunities 2. Economic conditions 3. Degree of flexibility 4. Availability of social supports

3

Which client would a nurse recognize as being at highest risk for the development of an AD? 1. A young married woman 2. An elderly unmarried man 3. A young unmarried woman 4. A young unmarried man

3

A 20-year-old client and a 60-year-old client have had drunk driving accidents and are both experiencing extreme anxiety. From a psychosocial theory perspective, which of these clients would be predisposed to the diagnosis of adjustment disorder? 1. The 60-year-old, because of memory deficits. 2. The 60-year-old, because of decreased cognitive processing ability. 3. The 20-year-old, because of limited cognitive experiences. 4. The 20-year-old, because of lack of developmental maturity.

4

A client, who recently delivered a stillborn baby, has a diagnosis of adjustment disorder unspecified. The nurse case manager should expect which client presentation that is characteristic of this diagnosis? 1. The client worries continually and appears nervous and jittery. 2. The client complains of a depressed mood, is tearful, and feels hopeless. 3. The client is belligerent, violates others' rights, and defaults on legal responsibilities. 4. The client complains of many physical ailments, refuses to socialize, and quits her job.

4

A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed? 1. "The trauma that women experience is more likely to be sexual assault and child sexual abuse." 2. "The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury." 3. "After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD)." 4. "Research shows that PTSD is more common in men than in women."

4

Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder? 1. Adjustment disorder 2. Generalized anxiety disorder 3. Panic disorder 4. Post-traumatic stress disorder

4

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)? 1. Anxiety, feelings of hopelessness, and worry 2. Truancy, vandalism, and fighting 3. Nervousness, worry, and jitteriness 4. Depressed mood, tearfulness, and hopelessness

4

The patient has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this patient? Select all that apply. A. IV normal saline B. calcium containing antacids C. IV potassium phosphate D. encouraging milk intake E. increasing vitamin D intake

A, B. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate.

You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? A. The potassium level may be increased if the patient has renal nephropathy. B. The patient may be excreting extra sodium and retaining potassium because of malnutrition. C. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. D. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. E. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.

A, C, D. Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A. Auscultate dependent portions of lungs B. Check color of urine C. Assess muscle strength D. Check skin turgor over sternum or shin

A. Auscultate dependent portions of the lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults.

A patient who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this patient? A. Digoxin toxicity may occur. B. A higher dose of digoxin may be needed. C. A diuretic may be needed. D. Fluid volume deficit may occur.

A. Digoxin toxicity may occur. Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure.

The home health nurse notes that an elderly patient has a low serum protein level. The nurse will plan to assess for A. edema B. Pallor C. Confusion D. Restlessness

A. Edema Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

The nursing care for a patient with hyponatremia includes A. Fluid restriction. B. Administration of hypotonic IV fluids. C. Administration of a cation-exchange resin. D. Increased water intake for patients on nasogastric suction.

A. Fluid restriction. In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.

You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? A. Sodium 136 mEq/L, potassium 4.5 mEq/L B. Sodium 145 mEq/L, potassium 4.8 mEq/L C. Sodium 135 mEq/L, potassium 3.6 mEq/L D. Sodium 144 mEq/L, potassium 3.7 mEq/L

A. Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

An elderly patient with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia? A. hypotension, warmth, and sweating B. nausea and vomiting C. hyperreflexia D. excessive urination

A. hypotension, warmth, and sweating Elevations in magnesium levels are accompanied by hypotension, warmth, and sweating.

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? 1. "I will need scheduled blood work in order to monitor for toxic levels of this drug." 2. "I won't stop taking this medication abruptly because there could be serious complications." 3. "I will not drink alcohol while taking this medication." 4. "I won't take extra doses of this drug because I can become addicted."

ANS: 1 Rationale: The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. This intervention is used when taking lithium (Eskalith) for the treatment of bipolar disorder. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing response? 1. "I know it's frightening, but try to remind yourself that this will only last a short time." 2. "Death from a panic attack happens so infrequently that there is no need to worry." 3. "Most people who experience panic attacks have feelings of impending doom." 4. "Tell me why you think you are going to die every time you have a panic attack."

ANS: 1 Rationale: The most appropriate nursing response to the client's concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours. When the nurse states that "Most people who experience panic attacks..." the nurse depersonalizes and belittles the client's feeling

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? 1. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." 2. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." 3. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." 4. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

ANS: 1 Rationale: The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and the related symptoms.

An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.) 1. Mirror checking 2. Excessive grooming 3. History of an eating disorder 4. History of delusional thinking 5. Skin picking

ANS: 1, 2, 5 Rationale: The DSM-5 lists preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others as a diagnostic criteria for the diagnosis of BDD. Also listed is that at some point during the course of the disorder, the person has performed repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or reassurance seeking.

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) 1. Encourage the client to recognize the signs of escalating anxiety. 2. Encourage the client to avoid any situation that causes stress. 3. Encourage the client to employ newly learned relaxation techniques. 4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. 5. Encourage the client to avoid caffeinated products

ANS: 1, 3, 4, 5 Rationale: Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety and because not all situations are easily avoidable

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? 1. The client will refrain from ritualistic behaviors during daylight hours. 2. The client will wake early enough to complete rituals prior to breakfast. 3. The client will participate in three unit activities by day three. 4. The client will substitute a productive activity for rituals by day one.

ANS: 2 Rationale: An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and begin to gradually limit the time allowed for rituals

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate? 1. High doses of tricyclic medications will be required for effective treatment of OCD. 2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. 3. The dose of Luvox is low because of the side effect of daytime drowsiness. 4. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned.

ANS: 2 Rationale: The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness

A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred? 1. Onset of symptoms most commonly occurs in early adolescence and persists until midlife. 2. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years. 3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death. 4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

ANS: 2 Rationale: The onset of the symptoms of agoraphobia most commonly occurs in the 20s and 30s and persists for many years

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.) 1. Benzodiazepine therapy 2. Systematic desensitization 3. Imploding (flooding) 4. Assertiveness training 5. Aversion therapy

ANS: 2, 3 Rationale: The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time

A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide? 1. "Using your imagination, we will attempt to achieve a state of relaxation." 2. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." 3. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." 4. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: 3 Rationale: The nurse should explain to the client that when participating in systematic desensitization he or she will go through a series of increasingly anxiety-provoking steps that will gradually increase tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? 1. Long-term treatment with diazepam (Valium) 2. Acute symptom control with citalopram (Celexa) 3. Long-term treatment with buspirone (BuSpar) 4. Acute symptom control with ziprasidone (Geodon)

ANS: 3 Rationale: The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? 1. Distract the client with other activities whenever ritual behaviors begin. 2. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. 3. Lock the room to discourage ritualistic behavior. 4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: 4 Rationale: The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to control interrupting anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions, because they do not help the client gain insight.

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? 1. Sublimation 2. Dissociation 3. Rationalization 4. Intellectualization

ANS: 4 Rationale: The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual process of logic, reasoning, and analysis.

What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? 1. GAD is acute in nature, and panic disorder is chronic. 2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. 3. Hyperventilation is a common symptom in GAD and rare in panic disorder. 4. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: 4 Rationale: The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse's first priority? 1. Generalized anxiety disorder and a nursing diagnosis of fear 2. Altered sensory perception and a nursing diagnosis of panic disorder 3. Pain disorder and a nursing diagnosis of altered role performance 4. Panic disorder and a nursing diagnosis of anxiety

ANS: 4 Rationale: The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror

A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol use disorder B. History of personality disorder C. History of schizophrenia D. History of hypertension

ANS: A Rationale: The nurse should question a prescription of alprazolam for acute anxiety if the client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance use disorder may be more likely to abuse other addictive substances.

During her aunt's wake, a four-year-old child runs up to the casket before a mother can stop her. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child? A. Complicated grieving B. Altered family processes C. Ineffective coping D. Body image disturbance

ANS: C Rationale: Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling disorder, or trichotillomania, may be assigned

A college student is unable to take a final exam owing to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Non-adherence R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

ANS: C Rationale: The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that will improve the client's healthy coping skills and reduce anxiety.

Antianxiety drugs are also called ______________________ and minor tranquilizers.

ANS: anxiolytics Rationale: Antianxiety drugs are also called anxiolytics and minor tranquilizers. Antianxiety agents are used in the treatment of anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle spasms, convulsive disorders, status epilepticus, and preoperative sedation.

A nurse would recognize which treatment as most commonly used for AD and its appropriate rationale? 1. Psychotherapy; to examine the stressor and confront unresolved issues 2. Fluoxetine (Prozac); to stabilize mood and resolve symptoms 3. Eye movement desensitization therapy; to reprocess traumatic events 4. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety

Ans: 1

A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client's plan of care? 1. The client will have no flashbacks. 2. The client will be able to feel a full range of emotions by discharge. 3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. 4. The client will refrain from discussing the traumatic event.

Ans: 3

A patient who has been hospitalized for 2 days has been receiving normal saline IV at 100 ml/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding by the nurse is the priority to report to the health care provider? A. Serum sodium level of 138 mEq/L B. Gradually decreasing level of consciousness C. Oral temperature of 100.1 degrees Fahrenheit with bibasilar lung crackles D. Weight gain of 2 pounds above the admission weight

B. Gradually decreasing level of consciousness The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

Which of the following nursing interventions is most appropriate when caring for a patient with dehydration? A. Auscultate lung sounds equally B. Monitor daily weight and intake and output C. Monitor blood pressure for increases D. Encourage the patient to reduce sodium intake

B. Monitor daily weight and intake and output Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 ml of body water.

The nurse inserts a nasogastric tube and it immediately drains 1000 mL of fluid. Which of the following electrolyte levels is of greatest concern at this time? A. Sodium B. Potassium C. Chloride D. Carbon dioxide

B. Potassium Hypokalemia is almost universal complication of loss of gastric hydrochloric acid. Metabolic alkalosis results. Other electrolytes may be affected, but not to the degree of potassium homeostasis is altered.

A patient is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered A. directly into the venous access line. B. mixed in the prescribed intravenous fluid. C. via a rectal suppository. D. via intramuscular injection.

B. mixed in the prescribed intravenous fluid. The intravenous route is the recommended route for diluted potassium.

A 35-year-old female patient comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this patient? A. Drink one glass of red wine per day. B. Avoid the sun. C. Milk and milk-based products will ensure an adequate calcium intake. D. Red meat is the protein source of choice.

C. Milk and milk-based products will ensure an adequate calcium intake. This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products.

A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this patient at risk for developing? A. pulmonary edema B. atrial dysrhythmias C. cerebral bleeding D. stress fractures

C. cerebral bleeding The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding.

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? A. Fluid movement from the blood vessels into the cells B. Fluid movement from the interstitial spaces into the cells C. Fluid movement from the blood vessels into interstitial spaces D. Fluid movement from the interstitial space into the blood vessels

D. Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? A. Sodium falling to 138 mEq/L B. Potassium rising to 41. mEq/L C. Magnesium rising to 2.9 mg/dL D. Phosphorus falling to 2.1 mg/dL

D. Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.

A patient is admitted for treatment of hypercalcemia. The nurse realizes that this patient's intravenous fluids will most likely be which of the following? A. dextrose 5% & water B. dextrose 5% & ? normal saline C. dextrose 5% & ? normal saline D. normal saline

D. normal saline Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.

The nurse is admitting a patient who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder? A. calcium B. magnesium C. phosphorus D. potassium

D. potassium Because the kidneys are the principal organs involved in the elimination of potassium.