NURS 222: Week 4

Ed, and 18-year old male, hosted a party at his parent's house while his parents were out of town. It was lit, to say the least. When Ed's parents returned, they were infuriated by how messy the house was. Ed apologized, and gave them a $50 gift card to Applebee's. Which defense mechanism is Ed using?

Undoing

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation?

Use assertiveness techniques

Benzodiazepines important info

Very addictive! Can cause dependence. They are generally used short term. Withdrawal symptoms Anxiety, insomnia, diaphoresis, tremors, delirium, seizures

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

"Acquaintance rape often involves alcohol"

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will administer prophylactic treatment for sexually transmitted infections, like chlamydia."

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication?

"I will need to discontinue this medication slowly."

A nurse is caring for a client who has generalized anxiety disorder and is experiencing sever anxiety. Which of the following statements actions should the nurse make?

"Tell me about how you are feeling right now"

A nurse observes a male client who is hyperactive and intrusive sitting very close to a female client with his arm around her shoulders. The nurse hears the male client tell a sexually explicit joke. The nurse approaches the client and asks him to walk down the hallway. Which statement by the nurse should benefit the client?

"Telling sexual jokes and touching others is not permitted here"

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding?

"When I have to pick up extra work, I feel overwhelmed. I need to focus on my own responsibilities"

A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make?

"You believe this wouldn't have happened if you hadn't been out alone?"

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

"cognitive reframing will help me change my irrational thoughts to something positive"

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by ta member of the group indicates an understanding?

"pregnancy increases the risk for violence form a spouse or partner"

Stress reduction is likely to result in which of the following?

-Reduced pain -Lower blood pressure -decreased gastrointestinal problems

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response?

-depressed immune system -increased blood pressure -unhappiness

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client?

-discuss prior use of coping mechanisms with the client -demonstrate a calm manner while using simple and clear directions

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

-excessive worry for 6 months -restlessness -sleep disturance

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority

Advise the client about the location of safe houses and shelters.

Which intervention is least appropriate for a nurse to use with a rape victim?

Allow the client to shower and brush her teeth before an examination

A client is experiencing sudden, moderate level anxiety. The nurse would anticipate that the psychiatrist would most likely prescribe which medication?

Alprazolam

Benzodiazepines

Alprazolam (Xanax) Diazepam (Valium) Lorazepam (Ativan) Chlordiazepoxide (Librium)

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. The nurse should:

Ask the client to come to a quiet area to talk to the nurse individually.

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

Assess the client's risk for self-harm

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

Attempt to reduce anxiety

A client presents in the ER after being sexually assaulted. She is physiologically stable, but emotionally distraught. Which nursing action should receive priority?

Attempt to reduce the client's anxiety level

Non-benzodiazepines

Buspirone (Buspar) Diphenhydramine (Benadryl)

A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states, "I grind my teeth during the night, which causes pain in my mouth." The nurse should identify which of the following interventions as possible measures to manage the client's bruxism?

Concurrent administration of buspirone Use of a mouth guard Changing to a different class of anti-anxiety medication

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?

Denial

A patient nervously says, "financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off." The patient's pulse is 112/minute; respirations are 26/minute; and blood pressure is 166/88. Which nursing intervention will the nurse implement?

Direct the patient in slow and deep breathing via use of a positive, repeated word.

What is the most appropriate therapeutic intervention when helping a patient resolve their agoraphobia?

Discuss the client's fear of his/her feelings or sensations rather than the situation.

Benzodiazepines side effects

Drowsiness Dry mouth Acute toxicity Confusion Resp. depression Hypotension Anterograde amnesia Paradoxical response Anxiety, insomnia

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome?

Emotional outbursts Difficulty making decisions

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion?

Excessive stressors cause the client to experience stress

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome?

Hallucinations Diaphoresis Agitation

A client with chronic ongoing stress complains of physical symptoms. The nurse caring for him is aware that the most common chronic problem caused by stress is which of the following?

Headaches

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority?

Identify the client's level of orientation

What would a client experience during a progressive relaxation session?

Instruction in sequential tensing and relaxing of various muscle groups until the entire body is relaxed

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

Intentionally causing someone to fall is an example of physical violence

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis?

Marriage

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "this is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety?

Moderate

Diphenhydramine

Not addictive May cause anticholinergic symptoms High doses = sleeepy

Buspirone

Not addictive Preg B not while breastfeeding NO Grapefruit, St. John's wort, erythromycin, MAOI

During an initial interview with parents, a nurse suspects child abuse What behavior displayed by the parents would lead the nurse to be suspicious?

Overconcern

A nurse is closely monitoring a newly admitted client who is anxious. At what anxiety level might this client become assaultive and a potential threat to himself and others?

Panic

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe?

Paroxetine (antidepressant) Lorazepam (benzo)

Benzodiazepines contraindications

Pregnancy risk D Sleep apnea Respiratory depression Glaucoma Hx of sub abuse

Lorazepam is prescribed for a client who has a generalized anxiety disorder. Which of the following instructions is most important for the nurse to give the client?

Prolonged use can result in dependence

A nurse is caring for a 23 year old client with schizophrenia. When the patient's father shows up during visitation hours, the client lies down in bed, curls up in a ball, and sucks his thumb. Which of the following defense mechanisms is the client exhibiting?

Regression

A client wants to know about relaxation techniques. What does the nurse say to educate the client?

Relaxation techniques work best when they are practiced on a regular basis.

A nurse is teaching a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse provide?

Report confusion as a potential indication of toxicity

What is a nurse's responsibility when a child is suspected of being abused or neglected?

Reporting of suspected abuse or neglect is required by law in each state.

A nurse is preparing to assess an infant.Which of the following is an expected finding of shaken baby syndrome?

Respiratory distress Retinal hemorrhage Altered level of consciousness Increase in head circumference

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse?

Round burn marks on the forearms Areas of ecchymosis on torso

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client and remain quiet.

A nurse assesses severe anxiety in a client. Which symptom would the nurse expect to see as a response of the sympathetic nervous system to anxiety?

Tachycardia

A 32-year-old male client is experiencing severe anxiety over a recent failed relationship. What nursing intervention should be given highest priority?

Take the client to a quiet environment

The nurse assesses a client to be at risk for self-mutilation and implements a safety contract with the client which client behavior indicates that the contract is working?

The client notifies staff when anxiety is increasing