Saunders Anxiety

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply. 1. Speak slowly. 2. Use simple statements. 3. Encourage the client to punch the wall. 4. Provide the client with high-calorie beverages. 5. Place the client in a room, alone at the end of the hall.

1,2,4

The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply. 1. Respond to stimuli 2. Conduct electrical impulses 3. Allow inward flow of sodium 4. Change membrane permeability 5. Release chemicals called neurotransmitters 6. Inhibit actions leading to a negative outcome

1,2,5

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. 1. Stay with the client. 2. Give detailed directions to the client. 3. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli. 5. Refrain from speaking until the client's anxiety is decreased.

1,3,4

The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply. 1. Rigidity 2. Hostility 3. Inflexibility 4. Adaptability 5. Repetitive thoughts 6. Ritualistic behavior

1,3,5,6

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account? 1. Sibling rivalry will cause regression to occur. 2. Fears of separation and mutilation are present. 3. Embarrassment of voiding irregularities is common. 4. Concern over size and function of the penis is present.

2

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what? 1. General anesthesia 2. To be left totally alone 3. To push with her contractions 4. To regain her breathing pattern

4

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations? 1. Minimize the time spent talking to the client. 2. Ask the client why he or she is reluctant to ask questions. 3. Ask a family member to be present when caring for the client. 4. Discuss common fears and questions expressed by other clients with the same diagnosis.

4

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should the nurse suggest to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1

A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic? 1. "Tell me about your concerns." 2. "Your husband called to say he's coming to be with you." 3. "Many women have this problem with no further complications." 4. "You have an excellent primary health care provider; if anyone can save your baby, she can."

1

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse? 1. "Tell me what you mean when you say that your baby has moved." 2. "The primary health care provider is all set to go and cannot change plans now." 3. "That would be impossible because babies don't move around this late." 4. "You need to listen to your primary health care provider; he knows what he is doing."

1

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate? 1. "Tell me what concerns you have." 2. "Don't worry. Everything will be fine." 3. "Why don't you want to have this test done?" 4. "The primary health care provider has scheduled this test for a reason."

1

A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem? 1. Fear about impending surgery 2. Lack of support related to the surgical procedure 3. Inadequate knowledge about the surgical procedure 4. Embarrassment about the changes in personal appearance

1

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness? 1. No rapid heartbeats or anxiety 2. No paranoid thought processes 3. No thought broadcasting or delusions 4. No reports of alcohol withdrawal symptoms

1

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? 1. The client is at increased risk for suicide. 2. The client is dealing with pertinent issues. 3. The client may need some time off the unit. 4. The client is responding normally to hospitalization.

1

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem? 1. Anxiety and fear 2. Feeling powerless 3. Lack of parenting skills 4. Lack of sensory perception

1

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which nursing action should the nurse do first? 1. Take the client to a quiet room. 2. Teach the client how to take deep breaths. 3. Ask the client to describe the events of the accident. 4. Ask the client to talk to the police about what she witnessed.

1

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1. A fear of leaving the house 2. A fear of riding in elevators 3. A fear of speaking in public 4. A fear of uncleanliness and the need to bathe every hour

1

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care? 1. Anxiety related to a slow progress of labor 2. Anxiety related to previous parenting issues 3. Anxiety related to the inability to achieve relaxation 4. Anxiety related to physical and emotional maternal exhaustion

1

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time? 1. Notify the registered nurse (RN). 2. Call security and persuade the client to stay. 3. Help the client pack his or her personal belongings in preparation for discharge. 4. Inform the client that discharge is not possible because of the type of admission process involved.

1

Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety? 1. Stay with the client until the medication becomes effective. 2. Crush the medication and disguise it in the client's meal items. 3. Ask the client why he or she is experiencing so much anxiety. 4. Explain that restricting alcohol is not necessary while taking this medication.

1

The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse should expect to observe? Select all that apply. 1. Apraxia 2. Aphasia 3. Agnosia 4. Hyperorality 5. Somatization 6. Operant conditioning

1,2,3,4

The nurse is caring for a mental health client who has been prescribed a benzodiazepine called chlorazapate. Which are the principal indications for this medication? Select all that apply. 1. Anxiety 2. Insomnia 3. Seizure disorders 4. Alcohol withdrawal 5. Postpartum depression 6. Obsessive-compulsive disorder (OCD)

1,2,3,4

A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply. 1. Depression 2. Substance abuse 3. Potential for violence 4. Adverse childhood events 5. Posttraumatic stress disorder (PTSD) 6. Obsessive-compulsive disorder (OCD)

1,2,4,5

The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply. 1. Zoophobia 2. Xenophobia 3. Alonophobia 4. Agoraphobia 5. Glossophobia 6. Germophobia

1,2,4,5

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply. 1. Reinforce the client's problem-solving abilities. 2. Focus attention on the client's physical complaints. 3. Voice doubt in the reality of the client's physical symptoms. 4. Assess "secondary gains" that the somatic illness provides the client. 5. Only spend time with the client when physical illness is not discussed.

1,4

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image. The client reports an extreme fear of public speaking. The nurse recognizes that this client is suffering from social phobia. Which are some other manifestations of social phobias? Select all that apply. 1. Performing badly on stage 2. Being afraid of strangers 3. Excessive anxiety when riding in an elevator 4. Looking awkward while eating or drinking in public 5. Not being able to answer questions in a classroom 6. Fear of saying something that sounds foolish in public

1,4,5,6

A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear? 1. "The pain medication that I give you will take these feelings away." 2. "This aching and cramping are normal and temporary and will subside." 3. "This pain is not real pain and relaxation exercises will help it go away." 4. "This always occurs after the surgery, and we will teach you ways to deal with it."

2

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety? 1. Reassure the mother that the child will be fine after she leaves. 2. Ask the mother if she would like to stay overnight with the child. 3. Give the mother the telephone number of the pediatric unit, and tell the mother to call at any time. 4. Tell the mother to bring the child's favorite toys the next time she comes to the hospital to visit.

2

A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? 1. Increased pulse rate 2. Relief of apprehension 3. Decreased urine output 4. Increased blood pressure

2

A client is receiving thrombolytic therapy by continuous infusion. The client suddenly becomes extremely anxious and complains of itching. The nurse hears stridor, and on examination of the client, notes generalized urticaria and hypotension. Which should be the priority action of the nurse? 1. Administer oxygen and protamine sulfate. 2. Stop the infusion, and notify the registered nurse. 3. Cut the infusion rate in half, and sit the client up in bed. 4. Administer diphenhydramine and continue the infusion

2

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk? 1. Ask a friend or family member to donate blood ahead of time. 2. Arrange an autologous blood donation before the planned surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank.

2

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the primary health care provider whether this process should be delayed temporarily based on administration of which medication to the client in the last hour? 1. Digoxin 2. Lorazepam 3. Furosemide 4. Metoclopramide

2

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. Which intervention would be appropriate to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure the client knows all the correct medical terms so that he or she can understand what is happening.

2

A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." Which response by the nurse is appropriate? 1. "I think you are making the right decision to have the surgery." 2. "You have concerns about the surgical treatment for your condition?" 3. "You are very ill. Your primary health care provider has made the correct decision." 4. "There is no reason to worry. Your primary health care provider is a wonderful surgeon."

2

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? 1. The mother should restrict the daughter's socializing time with her friends. 2. The mother should restrict the amount of chocolate and caffeine products in the home. 3. The mother should keep her daughter out of school until she can adjust to the school environment. 4. The mother should consider taking time off of work to help her daughter readjust to the home environment.

2

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder? 1. Put the client in a supine position. 2. Provide emotional support and reassurance. 3. Withhold all sedative or antianxiety medications. 4. Tell the client to breathe very deeply but more slowly.

2

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time? 1. "No, we can't talk right now; it is bedtime." 2. "I can see that you're upset. I'm willing to listen." 3. "Try to get some sleep, and we will talk in the morning." 4. "I don't have time right now, but I'll get someone else to talk to you."

2

A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply. 1. Decreased pulse rate 2. Inability to think clearly 3. Inability to problem solve 4. Impulsively reacting to situations 5. Dry skin and mucous membranes

2,3

The nurse is admitting a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis? Select all that apply. 1. Fear of heights 2. Being on a bridge 3. Riding in an elevator 4. Being alone at home 5. Travelling in an airplane 6. Refusing to speak in public

2,3,4,5

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply. 1. Selective inattention 2. Oblivious to surroundings 3. Unable to focus on anything 4. Engaging in purposeless activity (walking around aimlessly) 5. Physical behavior may become erratic, uncoordinated, and impulsive. 6. Showing unproductive relief behavior (stomping, wringing hands, dropping things)

2,3,4,6

A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply. 1. Eupnea 2. Irritability 3. Moist skin 4. Bradycardia 5. Hypertension 6. Gastrointestinal disturbances

2,5,6

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3

A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse should provide reassurance to the client about the procedure? 1. "You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly." 2. "The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic." 3. "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure." 4. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."

3

A client taking buspirone hydrochloride for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and interprets that the medication is effective if the client reports an absence of which sign/symptom? 1. Delusions 2. Paranoid thoughts 3. Palpitations and anxiety 4. Alcohol withdrawal signs/symptoms

3

A client who is taking lithium carbonate is scheduled for surgery. The nurse would reinforce what information in the preoperative teaching about this medication? 1. The medication will be discontinued a week before the surgery and resumed 1 week postoperatively. 2. The medication is to be taken until the day of surgery and resumed by injection immediately postoperatively. 3. The medication will be discontinued 1 to 2 days before the surgery and resumed as soon as full oral intake is allowed. 4. The medication will be discontinued several days before surgery and resumed by injection in the immediate postoperative period.

3

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first? 1. Restrain the client. 2. Fill out an incident report. 3. Remove both clients to a separate, safe location. 4. Call the hospital risk management department.

3

A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old child? 1. "The child will withdraw." 2. "Separation anxiety is not an issue in a 2-year-old." 3. "The child may ignore the parents when they visit." 4. "Two-year-olds usually adjust well to hospitalization."

3

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Persuade the client to stay a few more days. 3. Contact the primary health care provider (PHCP). 4. Tell the client that discharge is not possible at this time.

3

The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time? 1. Inability to cope 2. Deficient sensory perception 3. Fear about what is happening 4. Lack of control over the situation

3

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply. 1. Do not allow the client to express negative thoughts. 2. Immerse the client with all the details of past events. 3. Request that the client perform undemanding, self-care tasks. 4. Reinforce teaching the client techniques to maintain present reality. 5. Assist the client to reestablish relationships with significant others.

3,4,5

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply. 1. Pain 2. Anger 3. Grief 4. Anxiety 5. Altered body image

3,4,5

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply. 1. Effects on environment 2. Dysfunctional behavior 3. Effects on problem solving 4. Effects on perceptual field 5. Healthy reaction necessary for survival 6. Physical and other defining characteristics

3,4,6

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on which information? 1. The object of the crisis 2. The client's coping mechanisms 3. The presence of support systems 4. The physical condition of the client

4

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely? 1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

4

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? 1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff." 3. "Your child has decided to have this treatment. You should be supportive of the decision." 4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? 1. Telling the client that the saw makes a frightening noise 2. Reassuring the client that no one has had an arm lacerated yet 3. Stating that the hot cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works

4

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety? 1. Emphasize the technical aspects of this type of delivery. 2. Decide how soon the client should see the baby after delivery. 3. Decrease the partner's anxiety by keeping him or her in the waiting area. 4. Encourage the client to discuss her concerns and desires regarding anesthesia options.

4

A client with carcinoma of the breast is admitted to the hospital for treatment with intravenous vincristine. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. After offering an open-ended question in reply, the client expresses how she feels. The nurse then gives the client information. The nurse makes which appropriate response to the client? 1. "Your friends are correct." 2. "You will not lose your hair." 3. "Hair loss may occur, but it will grow back just as it is now." 4. "Hair loss may occur, and it will grow back, but it may have a different color or texture."

4

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response should the nurse make to help reduce the maternal fears that the newborn will be born with an infection? 1. "Urinary infections during pregnancy are common. Your baby will be fine." 2. "Your developing baby cannot acquire an infection from you during pregnancy." 3. "You shouldn't worry about this because you received early prenatal care and are taking your prenatal vitamins." 4. "Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."

4

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as the priority at this time? 1. Altered tissue integrity 2. Urinary tract infection 3. Pain associated with the infection 4. Fear about the well-being of the fetus

4

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time? 1. Tell the client not to worry. 2. Refer the client to a counselor. 3. Ignore the client's unfounded concerns and continue. 4. Explain the purpose of the nurse's actions and answer all questions.

4

In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn? 1. Lack of ability to cope 2. Presence of grieving in a dysfunctional way 3. Lack of self-esteem with regard to caring for the newborn 4. Lack of knowledge regarding ability to care for the newborn

4

The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? 1. "Recuperation after cardiac surgery is generally slower for older people." 2. "It's important to get out of bed every day even if tired or weak at first." 3. "Fatigue, discomfort, and lack of appetite occur more commonly with older people and may last for 2 to 5 weeks." 4. "A daily, half-mile-long, brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

4

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client? 1. Demand active participation in care. 2. Monitor for obsessive-compulsive behavior. 3. Educate the client about self-care demands. 4. Establish a trusting nurse-client relationship.

4

The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate? 1. Defends the delusional thinking 2. Relinquishes the need for delusional thinking 3. Verbalizes the reasons for delusional thinking 4. Develops a relationship to help reduce the frequency of the delusions

4

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation? 1. Emotional immaturity 2. A stubborn personality 3. An undiagnosed psychiatric disorder 4. Acute anxiety and the need for support

4

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which action as the best strategy to assist the client in coping with the disease? 1. Ask family members if they wish a psychiatric consult. 2. Allow the client to deal with the disease in an individual fashion. 3. Encourage the client to visit with the pastoral care department chaplain. 4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4

The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client? 1. Group therapy 2. Medical diagnosis 3. Recreational therapy 4. Goals and objectives

4

The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse should make which response to the client? 1. "No, it is not painful." 2. "You will receive general anesthesia." 3. "You will be heavily medicated before the procedure." 4. "A local anesthetic will be given and will decrease the discomfort."

4