Anxiety

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? 1. "I'd be sure to have a panic attack if I left my house." 2. "I couldn't touch a public doorknob unless I wore gloves." 3. "Just the thought of getting into an elevator causes me to panic." 4. "Speaking to more than 1 or 2 people would be impossible for me."

1. "I'd be sure to have a panic attack if I left my house." Rationale: Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. The remaining options describe obsessive-compulsive behavior, claustrophobia, and a social phobia.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action? 1. Sit and talk with the client about the feelings. 2. Ask the assistive personnel to check on the client. 3. Administer the prescribed as-needed anti anxiety medication. 4. Call the client's primary health care provider to report the client's anxiety.

1. Sit and talk with the client about the feelings. Rationale: The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Anti Anxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.

What statement would the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety? 1. "Try not to worry so much." 2. "I can see that you are becoming upset." 3. "Everything is going to be all right; just relax." 4. "Why are you having trouble controlling your anxiety?"

2. "I can see that you are becoming upset." Rationale: The correct option is the only one that addresses the client's feelings and concerns. Avoid options that provide false reassurance and place the client's feelings on hold. Avoid options that ask "why"; this nontherapeutic communication technique will increase the client's anxiety.

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder? 1. "I'm always crying." 2. "I'm afraid to go outside." 3. "I keep reliving the abuse." 4. "I keep washing my hands over and over."

3. "I keep reliving the abuse." Rationale: In post-traumatic stress disorder, the client relives the traumatic experience. Only the correct option includes the defining characteristic symptom of post-traumatic stress disorder. Fear of going outside is characteristic of a phobia, while always crying may indicate depression. Excessive handwashing is a characteristic of obsessive-compulsive disorder.

Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1. Frequently expresses suicidal ideations 2. Leaves the dayroom when anyone else enters 3. Will take personal items from other clients' rooms 4. Requires constant reassurance whenever required to make a decision

3. Will take personal items from other clients' rooms Rationale: A central defining characteristic of the antisocial personality is disregard for the rights and feelings of others. Taking the belongings of others would demonstrate this characteristic. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of antisocial personality disorder.

A client is unwilling to go to church because the client's ex-partner goes there and the client feels that the ex-partner will laugh at and make fun of the client in church. Because of this hypersensitivity to a reaction from the ex-partner, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. Avoidant 2. Borderline 3. Schizotypal 4. Obsessive-compulsive

1. Avoidant Rationale:The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances Rationale:Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1. Daily medication therapy 2. Involvement with a support group 3. Intense stress management training 4. Short exposure to the phobic object

4. Short exposure to the phobic object Rationale: Systematic desensitization is a form of therapy in which the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, over a period of time, exposure is increased until the anxiety about or fear of the object or situation has ceased. Medication is associated with pharmacological therapy. While stress management techniques and self-help groups may be helpful, neither is the basis of this therapy.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism Rationale:The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? 1. Pain 2. Anxiety 3. Depression 4. Withdrawal

2. Anxiety Rationale: Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptoms.

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1. The medication is addicting. 2. Dizziness and nervousness may occur. 3. Tolerance can develop with this medication. 4. The medication can produce a sedating effect.

2. Dizziness and nervousness may occur. Rationale: Buspirone hydrochloride is an anxiolytic medication. Dizziness, nausea, headaches, nervousness, light-headedness, and excitement, which generally are not major problems, are side effects. Buspirone hydrochloride is not addicting, tolerance does not develop, and it is not sedating.

The nurse is teaching a client who is being started on imipramine about the medication. The nurse would inform the client to expect maximum desired effects at which time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration

2. In 2 to 3 weeks Rationale: The maximum therapeutic effects of imipramine may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect time periods.

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1. Delusions 2. Severe anxiety 3. Alcohol cravings 4. Paranoid thoughts

2. Severe anxiety Rationale: Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression. It is not recommended for the treatment of thought disorders (delusions), drug or alcohol cravings, or schizophrenia (paranoid thoughts).

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

3. Observing rigid rules and regulations Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.

A parent brings their child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse prepares to perform an assessment on the child, knowing that which finding would be of least concern for hepatitis? 1. Jaundice 2. Hepatomegaly 3. Dark-colored, frothy urine 4. Left upper abdominal quadrant pain

4. Left upper abdominal quadrant pain Rationale: Assessment findings in a child with hepatitis include right upper quadrant tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and frothy. Jaundice may be present and will be best assessed in the sclerae, nail beds, and mucous membranes.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit would expect to note which behaviors in the client? 1. Sad and tearful 2. Suspicious and hostile 3. Frightened and delusional 4. Rigidness in thought and inflexibility

4. Rigidness in thought and inflexibility Rationale: Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations Rationale:Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1. "I took an extra pill for anxiety and got through the funeral fairly well." 2. "I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." 3. "Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

4. "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle." Rationale: Generalizing fears to a specific place or situation is the hallmark of agoraphobia. Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety reduction. Taking extra anxiety medication would not indicate improvement. "Clock-watching" with regard to the medication schedule is also not a sign that the client is responding well to the treatment.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced." Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1. Assess the client's vital signs. 2. Identify the client's activity during the pain. 3. Assess for signs related to a panic disorder. 4. Determine the client's use of relaxation techniques.

1. Assess the client's vital signs. Rationale: Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.

1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron-deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption but is not helpful in replacing blood lost during surgery.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see that face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket."6"I have to wash my hands over and over again many times."

2. "I keep reliving the robbery." 3. "I see that face everywhere I go." 5. "I might have died over a few dollars in my pocket." Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

3. "You seem restless; tell me what is happening." Rationale: The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques would the nurse use while interacting with the client? Select all that apply. 1. Turn the client's favorite TV show on. 2. Ask the client to identify how they feel. 3. Help the client identify the cause of the anxiety. 4. Lean against the wall casually with arms crossed. 5. Observe for expressions of helplessness and hopelessness.

2. Ask the client to identify how they feel. 3. Help the client identify the cause of the anxiety. 5. Observe for expressions of helplessness and hopelessness. Rationale:If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, asking the client to identify what and how they are feeling and helping the client to identify the causes of the feelings increase the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease the anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

2. Evidence of the client's disturbed body image Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1. Dementia 2. Panic disorder 3. Multiple personality disorder 4. Post-traumatic stress disorder 5. Obsessive-compulsive disorder

2. Panic disorder 4. Post-traumatic stress disorder 5. Obsessive-compulsive disorder Rationale: Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would take 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 deeply but more rapidly.

2. Provide emotional support and reassurance. Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client would try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions

2. Rapid heartbeat or anxiety Rationale: Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety.

A client arrives in the emergency department in a crisis state, demonstrating signs of profound anxiety. What would the initial nursing assessment focus on? 1. The object of the crisis 2. The client's physical condition 3. The client's coping mechanisms 4. The presence of support systems

2. The client's physical condition Rationale: The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed with the mental health interview that involves the remaining options.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining 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 death of a loved one Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis or disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 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. "What leads you to seek help now?" Rationale: The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

The nurse is creating a plan of care for the client who is upset following the loss of a job and is verbalizing concerns regarding the ability to meet financial obligations. Which problem is the basis of the client's concerns? 1. Anxiety 2. Confusion about social roles 3. Inability to meet role expectations 4. Impairment of interactions among family members

3. Inability to meet role expectations Rationale: Inability to meet role expectations may be characterized by inability to meet basic needs such as financial obligations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a subjective experience that includes feelings of apprehension, uneasiness, uncertainty, or dread. Confusion is characterized by disorientation to time, place, client, and events; confusion about social roles relates to being unsure about social responsibilities. Impairment of interactions among family members may occur when the family has difficulty adapting or responding to the changes or traumatic experience of the member in crisis.

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? 1. Believes the attacker is in the emergency department 2. Detached, requiring gentle probing to respond to questions 3. Is pacing while describing the situation using a rapid speech pattern 4. Talks about being "panic stricken" that something else "bad" will happen

3. Is pacing while describing the situation using a rapid speech pattern Rationale: The client who has severe anxiety has significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. Option 1 describes fear and paranoia. Option 2 is characteristic of a withdrawn client or a client with depression. Option 4 describes a panic state. Panic is associated with a feeling of dread and terror and a sense of impending doom.

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concern regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? 1. Trusting the staff 2. Socializing with other clients at a holiday party 3. Making decisions about living arrangements after discharge 4. Identifying ways to minimize the tendency to be self-centered

3. Making decisions about living arrangements after discharge Rationale: A central defining characteristic of the dependent personality is the inability to make decisions with excessive dependence on others. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of dependent personality disorder.

A client with renal cell carcinoma of the left kidney is scheduled for nephrectomy. The right kidney appears normal at this time. The client is anxious about whether dialysis will ultimately be needed. The nurse would plan to use which information in discussions with the client to alleviate anxiety? 1. There is a strong likelihood that the client will need dialysis within 5 to 10 years. 2. There is absolutely no chance of needing dialysis because of the nature of the surgery. 3. One kidney is adequate to meet the needs of the body as long as it has normal function. 4. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery.

3. One kidney is adequate to meet the needs of the body as long as it has normal function. Rationale: Fear about having only one functioning kidney is common in clients who must undergo nephrectomy for renal cancer. These clients need emotional support and reassurance that the remaining kidney would be able to fully meet the body's metabolic needs, as long as it has normal function. Therefore, the remaining options are incorrect.

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. Remain with the client until the anxiety decreases. Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive disorder

3. Somatization disorder Rationale: Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

A client is anxious about an upcoming diagnostic procedure. The client's pupils are dilated, and the respiratory rate, heart rate, and blood pressure are increased from baseline. The nurse determines that the client's clinical manifestations are due to what type of physiological response? 1. Vagal 2. Peripheral nervous system 3. Sympathetic nervous system 4. Parasympathetic nervous system

3. Sympathetic nervous system Rationale:The sympathetic nervous system is responsible for the so-called fight or flight response, which is characterized by dilated pupils, increases in heart rate and cardiac output, and increases in respiratory rate and blood pressure. The sympathetic nervous system response affects some type of change in most systems of the body. The responses stated in the other options do not produce these effects.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care? 1. Monitor for repetitive behavior. 2. Demand active participation in care. 3. Educate the client about self-care needs. 4. Establish a trusting nurse-client relationship.

4. Establish a trusting nurse-client relationship. Rationale: The priority is to establish a trusting relationship with the client. Demanding anything from the client would never occur. The remaining options are appropriate components of the plan of care but are not the priority. A trusting nurse-client relationship needs to be established first.

The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Allow the client to complete the exercise program. 2. Interrupt the client and weigh the client immediately. 3. Tell the client that exercising rigorously is not allowed. 4. Interrupt the client and offer to take the client for a walk.

4. Interrupt the client and offer to take the client for a walk. Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that completing the exercise is not allowed will increase the client's anxiety.

The client tells the nurse they cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis? 1. A phobia 2. Generalized anxiety disorder 3. Post-traumatic stress disorder 4. Obsessive-compulsive disorder

4. Obsessive-compulsive disorder Rationale: A repetitive behavior that interferes with activities of daily living and functioning is indicative of obsessive-compulsive disorder (OCD). This repetitive behavior is not associated with phobias, generalized anxiety disorder, or post-traumatic stress disorder.

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 would incorporate which intervention as the best strategy to assist the client in coping with the illness? 1. Allow the client to deal with the disease in an individual fashion. 2. Ask family members whether they wish a psychiatric consultation. 3. Encourage the client to visit with the pastoral care department's chaplain. 4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

4. Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease. Rationale: A primary role of the nurse working with a client with TB is to teach the client about medication therapy. An anxious client may not absorb information optimally. The nurse continues to reinforce teaching using a variety of methods (repetition, teaching aids), and teaches the family about the medications as well. The most effective way of coping with the disease is to learn about the therapy that will eradicate it. This gives the client a measure of power over the situation and outcome. Allowing the client to deal with the disease in an individual fashion gives no active assistance to the client. Asking family members whether they wish a psychiatric consultation does not involve the client. Although visiting with the pastoral care department's chaplain may be helpful, it is not the best strategy among the options provided.

A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the best nursing action? 1. Ask a family member to stay with the client at all times. 2. Encourage the client to sleep until arterial blood gas results improve. 3. Ask the primary health care provider for a prescription for succinylcholine. 4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Rationale:Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse needs to speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How would the nurse respond to provide reassurance? 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 be treated prophylactically, and the client will not be contagious after 1 continuous week of medication therapy. 4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

4. The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale: Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client usually is not contagious after taking the medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or medication-resistant tuberculosis.