HCC II Coping ATI Assessment

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

The client states, "My heart is pounding out of my chest."

A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?

-The amygdala-centered (ACC) circuit of the brain is associated with feelings of panic.

A nurse in an emergency department is assessing a client for suspected cocaine intoxication. Which of the following findings should the nurse expect?

-Dilated pupils

A nurse has completed an assessment of a client whose parent recently died. Which of the following client statements is an indication that the client is experiencing death anxiety?

-"I just can't stop thinking about my own death. Life is so short."

A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply)

-"I think about being on my favorite beach vacation when I get anxious." -"I tense and release my muscles, starting with my feet." -"I see the glass as half-full when it starts looking empty." -I get 7 hours of sleep at night by skipping afternoon naps."

A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?

-"If I eat one piece of candy, I may as well eat ten."

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

-"In my dreams, all I can see are the wounded reaching out and trying to grab me."

A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

-"It sounds like you're having a difficult time."

A nurse is caring for a client who has anorexia nervosa and expresses anxiety about the weight gain restoration program. Which of the following statements should the nurse make?

-"What are your feelings about the restoration process."

A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?

-Agoraphobia

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

-Albumin

A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

-Anxiety

A nurse is caring for a client who has generalized anxiety disorder. The nurse should identify that which of the following statements describes anxiety as transdiagnostic in nature?

-Anxiety can manifest alongside other medical and psychiatric conditions.

A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?

-Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.

A nurse in an outpatient mental health clinic is caring for a client who has an eating disorder. Which of the following findings in the client's medical record indicated the client has bulimia nervosa?

-BMI 20.1 -Erosion of teeth, numerous dental caries. - Overeating with subsequent episodes of induced vomiting every weekday evening following work. -Taking over-the-counter laxative and diuretic medication every morning. -Frequent premature ventricular contractions (PVCs) -Potassium 3.2 mEq/L

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following prescriptions should the nurse clarify with the provider?

-Bisacodyl-Contraindicated -Mirtazapine- Anticipated -Haloperidol- Nonessential -Calcium- Anticipated -Multivitamin- Anticipated

A nurse is caring for an adolescent who was admitted with anorexia nervosa. Which of the following finding should the nurse expect?

-Bloating

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

-Constipation

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

-Decrease anxiety to a tolerable level.

A nurse is coaching four clients in the use of relaxation techniques to manage stress. Which of the following findings indicate the techniques are effective?

-Decreased blood pressure -Arousal reduction -Decreased heart rate -Increased peripheral skin temperature

A nurse is monitoring a client who has been diagnosed with post-traumatic stress disorder (PTSD). The nurse recognizes that people diagnosed with PTSD may exhibit symptoms similar to which of the following mental health disorders?

-Dissociative disorders -Substance use disorder -Depressive disorders -Anxiety disorders

A nurse is assessing a client who has acute cocaine toxicity. Which of the following findings should the nurse expect? (Select all that apply.)

-Fever -Tremor -Agitation

A nurse is caring for a client who has bulimia nervosa has a new prescription for a selective serotonin reuptake inhibitor (SSRI). Which of the following medications should the nurse anticipate administering?

-Fluoxetine.

A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?

-Gain 2 pounds of weight per week.

A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

-Generalized anxiety disorder

A nurse in an outpatient mental health clinic is discussing the development of anxiety-related disorders in children to a group of parents. The nurse should include that which of the following is an adverse childhood experience (ACE) that can contribute to the development of an anxiety disorder?

-Having a physical disability

(INCORRECT)A nurse is caring for a newborn in the postpartum unit. For each assessment finding, click to specify if the finding is consistent with Hypoglycemia, Neonatal Abstinence Syndrome, or Neonatal sepsis. Each finding may support more than 1 disease process.

-Hypoglycemia - Mother's Past Medical History, Laboratory Results, Respiratory Rate/Rhythm, Body Temperature, General Exam, Birth Weight, HEENT Exam -Neonatal Abstinence Syndrome - Respiratory Rate/Rhythm, General Exam -Neonatal Sepsis - Respiratory Rate/Rhythm, Body Temperature, General Exam, HEENT Exam

A nurse is caring for a client who describes extreme fear of having or acquiring a disease. The client is also exhibiting behaviors like repeated body checking. The nurse should identify that the client is exhibiting manifestations of which of the following disorders?

-Illness anxiety disorder

A nurse is working with a client who is displaying a disproportionate fear of having cancer. The nurse notes the client is seeking out medical care more frequently, has high anxiety, and believes they have cancer, despite no medical evidence to support this. Which of the following disorders is the client likely experiencing.

-Illness anxiety disorder

A nurse is providing care to a client who is preparing to go to surgery. Which of the following manifestations should the nurse expect in a client who experiencing a stress response?

-Increased blood pressure -Increased respiratory rate -Dilated pupils -Increased heart rate

A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

-Initiating suicide precautions.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client...

-Makes up stories when he is unable to remember actual events.

A nurse is setting goals for a client who has bulimia nervosa. Which of the following goals should the nurse identify as the priority?

-Medical stabilization

A nurse is teaching a group of clients about coping strategies to reduce stress. The nurse should include which of the following suggestions? (Select all that apply.)

-Participate in a yoga class. -Spend time with a pet. -Engage in meditation. -Adjust expectations about a situation.

A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?

-Regression

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply).

-Risk of depression, autoimmune disorders, and heart disease increases. -Immune system functioning decreases, and risk of cancer increases.

A nurse is caring for a client who has bulimia nervosa. Which of the following findings should the nurse expect?

-Russell's sign

A nurse is caring for a child whose guardians report that the child is consistently unable to speak during class and other social situations. The nurse should identify that the child is experiencing which of the following anxiety disorders?

-Selective mutism

A nurse is caring for a client who has posttraumatic stress disorder (PTSD) and is beginning psychopharmacology therapy. Which of the following medications is considered first-line treatment for symptoms of PTSD?

-Sertraline

A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?

-Stage 3 (severe)

A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the client states that they have been using cocaine at least once daily for the past 6 months. The nurse is collecting which of the following types of data from the client's account?

-Subjective

A nurse is reviewing the documentation for a newly admitted client and notes the following entry, "Client verbalizes the use of coping mechanisms when experiencing stress." Which of the following can the nurse expect when interacting with this client?

-The client adapts well to change.

A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress?

-The client consumed alcohol while taking this medication.

A nurse is providing care for a client who has generalized anxiety disorder using the SMART goal method. Which of the following goals contains all of the required elements?

-The client will verbalize the use of deep breathing relaxation techniques when feeling anxious by tomorrow morning at 1000.

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

-Threatening behavior

A nurse is caring for a client who was recently diagnosed with an opioid use disorder. They were a student in a local community college but were recently dismissed for failing their classes. Their previous diagnoses include anxiety, Crohn's disease, and chronic back pain due to a gymnastics injury in high school. Which of the following should the nurse identify as potential underlying reasons why the client might have started using opioids?

-To treat pain and ease anxiety

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?

-Urinary frequency

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

-Validate the client's feelings. -Establish rapport with the client. -Identify the cause of the anxiety

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

-Walk with the client at a gradually slower pace.

A nurse is caring for a newborn who is 56 hr old. A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?

Feeding: -Hypoglycemia -NAS Extremities: -Hypoglycemia -NAS Stools: -NAS Temperature: -Hypoglycemia