Anxiety Disorders
A client in a psychiatric facility is prescribed a selective serotonin reuptake inhibitor (SSRI) for depression. The client tells the nurse they have had three seizures after taking the drug for 2 weeks. What question would be appropriate to ask at this time? "Are you sure you have seizures or is it this your imagination?" "Have you stopped taking the drug to see if your seizures stop?" "Do you take any herbs, such as St. John's wort or evening primrose?" "Do any other members of your family have seizures?
"Do you take any herbs, such as St. John's wort or evening primrose?"
The nurse is caring for a client with posttraumatic stress disorder (PTSD) and the family informs the nurse that loud noises cause a serious anxiety response. Which explanation by the nurse would help the family understand the client's response? "After a trauma, the client can't respond to stimuli in an appropriate manner." "Clients commonly experience extreme fear of normal environmental stimuli." "Environmental triggers can cause the client to react emotionally." "The response indicates another emotional problem needs investigation."
"Environmental triggers can cause the client to react emotionally."
A client has been diagnosed with an anxiety disorder and is refusing any form of prescribed therapy and medication. The client states, "I am going to try to use an internet support group since it is free." What is the best response by the nurse? "I think that is a great idea and should be a good substitute for formal therapy." "I need to reinforce that any advice obtained from the internet should be used with caution." "It won't work and you will just end up on medication and therapy anyway." "Everyone with an anxiety disorder should also be on medication to help the symptoms."
"I need to reinforce that any advice obtained from the internet should be used with caution."
The nurse is instructing a client about using the antianxiety medication lorazepam. Which statement by the client indicates a need for further education? "If I have a sore throat, I should report it to the health care provider." "I usually drink a beer every night to help me sleep." "I shouldn't stop taking this medicine abruptly." "I should get up slowly from a sitting or lying position."
"I usually drink a beer every night to help me sleep."
A nurse is reinforcing instruction for a client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg by mouth three times per day. The nurse determines that the education regarding the client's diagnosis and medication has been effective when the client gives which response? "I'll avoid aged cheese." "I'll avoid caffeine." "I'll maintain adequate salt intake." "I'll avoid sunlight."
"I'll avoid caffeine."
The nurse is reinforcing education to a client that is demonstrating considerable anxiety about an impending surgical procedure. Which nursing intervention is most appropriate? Tell the client he should not keep his feelings to himself. Calmly ask the client to describe the procedure that is to be done. Tell the client that the nursing staff will help in any way they can. Reassure the client that there are many treatments for the problem.
Calmly ask the client to describe the procedure that is to be done.
The nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the compulsion. Based on this finding, the nurse should assess the client for which sign? Increased anxiety Depression Excessive fear Feelings of failure
Increased anxiety
A client tells the nurse that she has an overwhelming fear of having a heart attack. This client is most likely suffering from which disorder? Panic disorder Myctophobia Social anxiety disorder Generalized anxiety disorder
Panic disorder
The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder? Suicide precautions are instituted. Clients may come and go as they desire. Clients may eat anything that is facility prepared. A security guard is present at the door.
Suicide precautions are instituted.
The nurse is assigned to reinforce insulin administration education for a client with diabetes who is anxious. During which stage should the nurse reinforce education for the client? moderate stage of anxiety severe stage of anxiety panic stage of anxiety mild stage of anxiety
mild stage of anxiety
The nurse is caring for a client with a diagnosis of conversion disorder. Which clinical symptoms does the client demonstrate that correlate with this diagnosis? delusions of grandeur a feeling of dread accompanied by somatic signs feelings of depression or euphoria neurologic symptoms associated with psychological conflict or need
neurologic symptoms associated with psychological conflict or need
The nurse is reinforcing education for a client with generalized anxiety disorder (GAD). What statement made by the client indicates the education has been understood by the client? "I've cut back on my use of dairy products." "I've reduced my intake of carbohydrates." "I've stopped drinking so much diet cola." "I now eat less at dinner and before bedtime."
"I've stopped drinking so much diet cola."
During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam? "Discontinue the medication immediately if you experience nausea." "Notify the physician if you experience urine retention." "Inform the physician if you become pregnant or intend to do so." "Apply sunscreen to prevent photosensitivity."
"Inform the physician if you become pregnant or intend to do so."
A client is diagnosed with illness anxiety disorder. When assisting with the plan of care, which intervention should be included? Teach the client adaptive coping strategies. Confront the client with the statement, "It's all in your head." Help the client eliminate the stress in her life. Encourage the client to focus on identification of physical symptoms.
Teach the client adaptive coping strategies.
The nurse is gathering data from a client that arrives in the clinic with generalized anxiety disorder (GAD). What statement made by the client does the nurse determine correlates with this diagnosis? "I couldn't breath and thought I was having a heart attack on the train." "Every time I hear a loud noise, it takes my mind back to being in the war a year ago." "It makes me uncomfortable to be around people at a party." "I worry about things all of the time that I have no control over."
"I worry about things all of the time that I have no control over."
The nurse is assisting with the development of a plan of care for a client with generalized anxiety disorder (GAD). Which intervention is important to include? Assist the client to make plans for regular periods of leisure time. Encourage the client to engage in activities that increase feelings of power and self-esteem. Promote the client's interaction and socialization with others. Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped.
Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped.
A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. When collecting data on this client, which typical manifestation does the nurse anticipate? The client uses one act to negate a previous act. The client assumes an attitude that is the opposite of an impulse that the client harbors. The client believes his or her thoughts can control other people and events. The client thinks and talks about a particular idea or subject persistently.
The client assumes an attitude that is the opposite of an impulse that the client harbors.
A client is diagnosed with severe posttraumatic stress disorder (PTSD) and is prescribed a tricyclic antidepressant. Which outcome does the nurse observe for to determine success with the prescribed regimen? The client will have an increase in the ability to concentrate. The client will not experience the reenactment of the trauma. The client will suspend the grieving process. The client will not have hyperactivity and purposeless movements.
The client will not experience the reenactment of the trauma.
The nurse educator is discussing a case regarding a client with obsessive-compulsive disorder who tells the nurse that he or she must check the lock on his or her apartment door 25 times before leaving for an appointment. The nurse educator includes which information about what this behavior represents? The client's attempt to maintain the safety of his or her home The client's attempt to reduce anxiety The client's attempt to control his or her thoughts The client's attempt to call attention to himself or herself
The client's attempt to reduce anxiety
Which action by the nurse would help a client with conversion-disorder blindness to eat? Expect the client to feed himself after explaining the location of food on the tray. Establish a "buddy" system with other clients who can feed the client at each meal. See to the needs of the other clients in the dining room, then feed this client last. Feed the client.
Expect the client to feed himself after explaining the location of food on the tray.
A physician's order states to administer lorazepam, 20 mg by mouth twice per day, to treat anxiety. How should the nurse proceed? Administer the dose after dissolving the tablet in 30 ml of diluent. Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose. Administer the first dose when the client requests it. Question the prescribing physician about the use of the drug because it isn't indicated for anxiety.
Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose.
A client undergoing treatment for an anxiety disorder is being cared for by a nursing student. The nursing faculty asks the student When is such a disorder considered chronic and generalized? What timeframe does the student provide about the existence of the client's "excessive anxiety and worry about two or more life circumstances"? 4 months 2 months 6 months 12 months
6 months
During a panic attack, a client hyperventilates, becomes unable to speak, and reports symptoms that mimic those of a heart attack. Which nursing intervention would be best? Encourage the client to lie down on the bed; then turn off the lights and leave the room. Accompany the client to his room; remain there and provide instructions in short, simple statements. Encourage work on a craft project in the client's room. Encourage participation in milieu activities.
Accompany the client to his room; remain there and provide instructions in short, simple statements.
After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for this client? Giving sleep medication, as prescribed, to restore a normal sleep-wake cycle Recommending a high-protein, low-fat diet Exploring the meaning of the traumatic event with the client Allowing the client time to heal
Exploring the meaning of the traumatic event with the client
While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety? Paroxetine Bupropion Lorazepam Haloperidol
Lorazepam
A client reports having a difficult time settling down for sleep in the evening. What nursing intervention would assist the client in achieving a positive outcome? Reinforce the adverse effects of antipsychotic medication. Reinforce progressive muscle relaxation. Reinforce time management skills. Reinforce conflict resolution skills.
Reinforce progressive muscle relaxation.
A nurse is caring for a client diagnosed with panic disorder who begins to hyperventilate. What is the priority nursing action at this time? Shout for help and obtain assistance. Stay with the client to maintain safety. Help the client explore the reason for the anxiety. Teach the client relaxation exercises.
Stay with the client to maintain safety.
A nurse is caring for a client experiencing a panic attack. Which intervention by the nurse would be most appropriate? Ask the client about the cause of the attack. Tell the client to take deep breaths. Encourage the client to verbalize feelings. Tell the client to talk about the anxiety.
Tell the client to take deep breaths.
Lorazepam is often given along with a neuroleptic agent, such as haloperidol. What is the purpose of administering the drugs together? To increase the client's level of awareness and concentration To reduce anxiety and potentiate the sedative action of the neuroleptic To counteract extrapyramidal effects of the neuroleptic To manage depressed clients
To reduce anxiety and potentiate the sedative action of the neuroleptic
A nurse is assisting with discharge instructions for a client who is prescribed sertraline. The nurse should monitor the client for which adverse drug effects? Select all that apply. agranulocytosis agitation sleep disturbance dry mouth intermittent tachycardia Seizure
agitation sleep disturbance dry mouth
The nurse is caring for a client that has excessive fear of lightening. Which term would the nurse use to document "excessive fear of lightening"? pyrophobia gamophobia hydrophobia astraphobia
astraphobia
A client tells a nurse, "I feel that I'm losing my mind!" The nurse interprets this statement as most commonly associated with which disorder? nyctophobia obsessive-compulsive disorder social phobia panic disorder
panic disorder
A client with a diagnosis of generalized anxiety disorder (GAD) wants to stop taking lorazepam. Which important fact should the nurse discuss with the client about discontinuing the medication? stopping the drug can cause withdrawal symptoms stopping the drug decreases sleeping difficulties stopping the drug increases cognitive abilities stopping the drug may cause depression
stopping the drug can cause withdrawal symptoms
The nurse is providing group therapy for a group of adolescents who witnessed the violent death of a peer. Which outcome would best meet the needs of the students? to discuss the effect of the trauma on their lives to learn violence prevention strategies to develop trusting relationships among their peers to talk about appropriate expression of anger
to discuss the effect of the trauma on their lives
Which finding should the nurse expect when talking about school to a child diagnosed with a generalized anxiety disorder (GAD)? The child has gained 15 lb (6.8 kg) in the past month. The child has been fighting with peers for the past month. The child cannot stop lying to parents and teachers. The child expresses concerns about grades.
The child expresses concerns about grades.
A client was the lone survivor of a train crash 6 months ago. Which statement by the client would indicate a maladaptive response to the trauma? "I've started to sleep through the night." "I don't want to talk about it." "I'm able to concentrate on reading a book." "I jump when I hear a train whistle because it reminds me of the wreck."
"I don't want to talk about it."
A client diagnosed as having panic disorder is admitted to the inpatient psychiatric unit. Until admission, he or she had been a virtual prisoner in the house for 5 weeks because of agoraphobia, afraid to go outside even to buy food. The nurse, when planning care for this client, determines which action as this client's overall goal? To help control the client's symptoms To help the client participate in group therapy To help the client perform self-care activities To help the client function effectively in his or her environment
To help the client function effectively in his or her environment
The nurse notices that a client with obsessive-compulsive disorder washes his or her hands for long periods each day. What nursing intervention should the nurse implement in response to this compulsive behavior? Call attention to or attempt to prevent the behavior Urge the client to reduce the frequency of the behavior as rapidly as possible Designate times during which the client can focus on the behavior Discourage the client from verbalizing anxieties
Designate times during which the client can focus on the behavior
Which group therapy intervention would be of primary importance to a client with panic disorder? Work to eliminate manipulative behavior used for meeting needs. Explore how secondary gains are derived from the disorder. Learn the risk factors and other demographics associated with panic disorder. Discuss new ways of thinking and feeling about panic attacks.
Discuss new ways of thinking and feeling about panic attacks.
A nurse is collecting data on a client who is suffering from stress and anxiety. When collecting data from the client, the nurse interprets what reported symptom as a common physiologic response to stress and anxiety? urticaria sedation diarrhea vertigo
diarrhea
The nurse is caring for a client who expresses complaints of sweating, palpitations, and intense fear when speaking in front of a crowd. Which term would the nurse use to document these symptoms? phobia schizophrenia major depression obsessive-compulsive disorder
phobia
Which statement made by the nurse would be useful when reinforcing education for the client and family about phobias and the need for a strong support system? "The family plays a role in promoting client independence." "The need to be assertive can be reinforced by the family." "Use a family support system on a temporary basis." "The family must set limits on inappropriate behaviors."
"The family plays a role in promoting client independence."
A nurse notices that a client who came to the clinic for treatment of anxiety disorder has a strong body odor. What can the nurse do or say to help this client? Offer the client a room where he can freshen up before the physician examines him. Provide the client with personal care items that he can take home with him. Prepare the client for his examination and then leave the room. Ask the client basic hygiene questions to determine how frequently he bathes.
Ask the client basic hygiene questions to determine how frequently he bathes.
A 49-year-old painter who recently fractured his tibia worries about his finances because he can't work. To treat his anxiety, his physician prescribes buspirone, 5 mg by mouth three times per day. During buspirone therapy, the client should avoid which of the following drugs? Monoamine oxidase (MAO) inhibitors Beta-adrenergic blockers Antiparkinsonian drugs Antineoplastic drugs
Monoamine oxidase (MAO) inhibitors
The nurse is caring for a client with posttraumatic stress disorder (PTSD) experiencing a frightening flashback. The nurse can best offer reassurance of safety and security through which nursing action? acknowledging feelings of guilt or self-blame encouraging the client to talk about the traumatic event staying with the client assessing for maladaptive and coping strategies
staying with the client
A new client admitted to a psychiatric unit is diagnosed with functional neurologic symptom disorder. The client shows a lack of concern for the sudden paralysis, though the client's athletic abilities have always been a source of pride. The nurse understands that the client is demonstrating which condition? malingering acute dystonia la belle indifference secondary gain
la belle indifference
A mental health nurse in an outpatient clinic is caring for a client who is newly diagnosed with phobic disorder. Which individual counseling approach is best to assist the client in daily activities? Teach the client effective ways to problem-solve. Help the client identify the source of the anxiety. Have the client keep a daily journal. Develop strategies to prevent the client from using substances.
Help the client identify the source of the anxiety.
Which nursing intervention is the most appropriate for a client who had pseudoseizures and is diagnosed with functional neurologic symptom disorder? Explain that the pseudoseizures are imaginary. Promote dependence so that unfilled dependency needs are met. Encourage the client to discuss his feelings about the pseudoseizures. Promote independence and withdraw attention from the pseudoseizures.
Promote independence and withdraw attention from the pseudoseizures.
Which nursing intervention would be most helpful for a client experiencing a panic attack? Reducing intolerable stimuli by encouraging the client to stay in the room alone until the anxiety abates Staying with the client and remaining calm, confident, and reassuring Promoting the client's interaction with others to reduce anxiety through diversion Encouraging the client to identify what precipitated the attack
Staying with the client and remaining calm, confident, and reassuring
Which factor should the nurse be most concerned about when caring for a client taking an antianxiety medication? abrupt withdrawal transient hypertension diarrhea constipation
abrupt withdrawal
Change question to: A client is prescribed alprazolam therapy. Which dose related adverse reactions should the nurse have the client report to the health care provider? Select all that apply. hepatomegaly rash drowsiness urticaria ataxia
drowsiness ataxia
A client taking alprazolam reports lightheadedness and nausea every day while getting out of bed. Which action should the nurse take to objectively validate this client's problem? Obtain a blood chemical profile. Take the client's blood pressure. Teach Valsalva maneuver. Monitor body temperature.
Take the client's blood pressure.
A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when assisting with development of the plan of care? Preventing ritualistic behavior Giving the client adequate time to perform rituals Setting strict limits on compulsive behavior Increasing environmental stimulation
Giving the client adequate time to perform rituals
A client sees a spider while raking leaves. Immediately, the client's heart begins beating rapidly and the client breaks into a sweat. To which condition is the client's response related? anxiety triggered by sustained physical exertion anxiety triggered by re-experiencing a previously frightening event fear triggered by a known, specific object or event fear triggered by an attempt to go outside into a public place
fear triggered by a known, specific object or event
A 59-year-old client is scheduled for cardiac catheterization the next morning. His physician prescribed secobarbital sodium, 100 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that: sedatives cause predictable responses; hypnotics cause unpredictable ones. sedatives interact with few drugs; hypnotics interact with many. sedatives reduce excitement; hypnotics induce sleep. sedatives don't depress respirations; hypnotics do.
sedatives reduce excitement; hypnotics induce sleep.
A nurse is caring for a client suspected of having posttraumatic stress disorder (PTSD). The nurse is aware that the client is also commonly at high risk for developing which condition? schizophrenia self-harm and violent behavior eating disorder "sundown" syndrome
self-harm and violent behavior
A client with obsessive-compulsive disorder and ritualistic behavior must brush the hair back from his forehead 15 times before carrying out any activity. The nurse notices that the client's hair is thinning and the skin on the forehead is irritated — possible effects of this ritual. When planning the client's care, the nurse should assign highest priority to: helping the client identify how the ritualistic behavior interferes with daily activities. setting consistent limits on the ritualistic behavior if it harms the client or others. using problem solving to help the client manage anxiety more effectively. exploring the purpose of the ritualistic behavior.
setting consistent limits on the ritualistic behavior if it harms the client or others.
Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder? to cope with delusional thinking to protect the client from family conflict to provide attention for the individual to prevent or relieve symptoms of anxiety
to prevent or relieve symptoms of anxiety
A client is refusing all medications and is having difficulty breathing, with a respiratory rate of 34 breaths/minute and anxiety. What is the priority nursing action? Notify the health care provider of the status of this client. Withhold the medication until the next scheduled dose. Encourage the client to take some of her medications. Put the medicine in applesauce to give it without the client's knowledge.
Notify the health care provider of the status of this client.
An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. When gathering data from the client, which behaviors would be characterized as compulsions? Select all that apply. checking and rechecking that the television is turned off before going to school brushing teeth three times per day Wanting to play the same video game each night. repeatedly washing the hands routinely climbing up and down a flight of stairs three times before leaving the house feeding the dog the same meal every day
checking and rechecking that the television is turned off before going to school repeatedly washing the hands routinely climbing up and down a flight of stairs three times before leaving the house
While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take? Notify the physician upon arrival at the operating room. Inform the operating room nurse of the client's statement. Read the client's medical record and inform her about the anticipated procedure. Return the client to her room and call the operating room to cancel the surgery.
Notify the physician upon arrival at the operating room.
The nurse is caring for a client who has been diagnosed as having social anxiety disorder. Which intervention would be appropriate for the nurse to encourage the client to develop? being in situations where the client is alone staying at home all the time public speaking having to shake hands and be exposed to others' germs
public speaking
Which therapeutic strategy is used to reduce anxiety in a client diagnosed with illness anxiety disorder? suicide precautions relaxation exercises pharmacological intervention electroconvulsive therapy
relaxation exercises
The nurse is assisting with the development of a plan of care for a client with illness anxiety disorder. What would be an appropriate goal for this client? determining the cause of a sleep disturbance relieving the fear of serious illness recovering the lost or altered function giving positive reinforcement for accomplishments related to physical appearance
relieving the fear of serious illness
The nurse is gathering data from a client with generalized anxiety disorder (GAD). When observing for muscle tension, what symptoms would most likely be exhibited? tachycardia difficulty sleeping strong startle response restlessness
restlessness
A client with a tic disorder has tried to use stress reduction techniques without success. Which medication does the nurse anticipate the client may be prescribed for treatment? clonidine methylphenidate risperidone atomoxetine
risperidone
A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, which action should the nurse first implement? Ask what the client is upset about Administer an antianxiety medication, as prescribed, and instruct the client to lie down in his room. Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught. Reassure the client that the symptoms will disappear after he or she lies down and relaxes.
Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught.
A client who recently developed paralysis of the arms is diagnosed with functional neurologic symptom disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the plan of care? Insisting that the client eat without assistance Working with the client rather than the family Exercising the client's arms regularly Teaching the client how to use nonpharmacologic pain-control methods
Exercising the client's arms regularly
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time? Hopelessness Disturbed personal identity Ineffective coping Risk for injury
Risk for injury
The nurse is caring for a client who is agitated and is trying to get out of bed. What should the nurse do first to keep the client free of injury? Keep side rails up. Apply a vest restraint. Administer alprazolam 0.5 mg orally once a day. Ask the unlicensed assistive personnel to sit with the client.
Ask the unlicensed assistive personnel to sit with the client.
A nurse is caring for a client recently diagnosed with cancer and experiencing severe anxiety. Which interventions should the nurse include in the care plan? Select all that apply. Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Teach the stages of grieving to the client. Provide distractions for the client during periods of stress. Maintain a calm, nonthreatening environment. Explain relevant aspects of chemotherapy. Encourage the client to verbalize concerns regarding the diagnosis.
Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress. Maintain a calm, nonthreatening environment. Encourage the client to verbalize concerns regarding the diagnosis.
A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing the beating of his wife at gunpoint, he has been unable to move his arms, complaining that they are paralyzed. When planning the client's care, the nurse should incorporate nursing interventions with which focus? Talking about topics other than the beating to avoid causing anxiety Helping the client identify and verbalize feelings about the incident Convincing the client that his arms are not paralyzed Developing rehabilitation strategies to help the client learn to live with the disability
Helping the client identify and verbalize feelings about the incident
A home health nurse is caring for a client diagnosed with a functional neurologic symptom disorder manifested by paralysis in the left arm. An organic cause for the deficit has been ruled out. Which nursing intervention is most appropriate for this client? Perform all physical tasks for the client to foster dependence. Allot an hour each day to discuss the paralysis and its cause. Identify primary or secondary gains that the physical symptom provides. Allow the client to withdraw from all physical activities.
Identify primary or secondary gains that the physical symptom provides.
A client suffering post-traumatic stress disorder is prescribed sertraline, 50 mg by mouth once daily. Which actions should the nurse take when administering this drug? Select all that apply. Mix the oral concentrate with 4 oz (120 mL) of water, ginger ale, or lemon-lime soda. Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations. Administer the drug at bedtime. Advise the client to use caution when performing hazardous tasks that require alertness. Administer the oral solution immediately after dilution.
Mix the oral concentrate with 4 oz (120 mL) of water, ginger ale, or lemon-lime soda. Instruct the client to check with the prescriber or pharmacist before taking over-the-counter preparations. Advise the client to use caution when performing hazardous tasks that require alertness. Administer the oral solution immediately after dilution.
Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his or her hands for 18 minutes, comb his or her hair 444 strokes, and switch the bathroom light on and off 44 times. When creating the plan of care, what is the most appropriate goal for this client? Systematically decrease the number of repetitions of rituals and the amount of time spent performing them. Allow ample time for the client to complete all rituals before each meal. Omit one unacceptable behavior each day. Increase the client's acceptance of therapeutic drug use.
Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.
A client is admitted for abrupt onset of paralysis in the left arm. Although no physiologic cause has been found, the symptoms are exacerbated when the client speaks about losing custody of children in a recent divorce. The nurse determines these findings are characteristic of what disorder? delusional disorder functional neurologic symptom disorder body dysmorphic disorder factitious disease
functional neurologic symptom disorder
A student nurse is preparing to administer an injection to a client. The instructor asked the student questions related to the administration of the injection. The student did not hear the questions, her muscles became tense, and her hands sweaty. The student nurse may be experiencing which level of anxiety? severe moderate panic mild
moderate
The nurse is caring for a client who complains of a choking sensation, racing heart, dizziness and fearfulness. Which term would the nurse use to document these symptoms? obsessive-compulsive disorder panic disorder substance abuse phobia
panic disorder
The nurse notices that a client with obsessive-compulsive disorder dresses and undresses numerous times each day. Which comment by the nurse would be therapeutic? "I saw you change clothes several times today. That must be very tiring." "Try to dress only once per day so you won't be so tired." "It bothers me to see you always so busy." "It's foolish to change clothes so many times in one day."
"I saw you change clothes several times today. That must be very tiring."
A nurse is reinforcing education for a client who has been prescribed buspirone for long-term treatment of anxiety. The nurse determines that the education has been effective when which statement is made by the client? "I will not stop the medicine if I become pregnant." "I will not take the medicine with my meals." "I will take the medicine only when I feel an anxiety attack coming on." "I will not take the medicine with grapefruit juice."
"I will not take the medicine with grapefruit juice."
A client with chronic anxiety disorder reports chest pain. Which nursing intervention is mostappropriate? Obtain vital signs. Stay with the client. Administer prescribed anti-anxiety medication. Reassure the client that the episode will pass.
Obtain vital signs.
Which nursing interventions would be most appropriate in assisting a client to cope with stress? Select all that apply. Plan care for client. Teach relaxation exercises. Establish a trusting relationship. Encourage verbalization of feelings. Encourage increase in workload. Minimize environmental stimuli.
Teach relaxation exercises. Establish a trusting relationship. Encourage verbalization of feelings. Encourage increase in workload. Minimize environmental stimuli.
Parents of an adolescent are concerned that their child has been irritable, hasn't been sleeping for 6 months, and is not engaging in social activities. Which outcome developed by the health care team would be appropriate for this client? The parents will impose strict behavior guidelines for the client to follow. The parents will stop worrying about the client. The client will obtain appropriate mental health services. The client will sleep well at night.
The client will obtain appropriate mental health services.
A client with illness anxiety disorder reports pain in their right side that they haven't had before. Which response is the most appropriate? "Tell me about this new pain you're having. You'll miss group therapy today." "I'll call your health care provider and see if he or she will order a new pain medication. Why don't you get some rest for now?" "It's time for group therapy now." "I'll report this pain to your physician. In the meantime, group therapy starts in 5 minutes. You must leave now to be on time."
"I'll report this pain to your physician. In the meantime, group therapy starts in 5 minutes. You must leave now to be on time."
The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder (PTSD) can be demonstrated by which client self-report? "I've lost my craving for alcohol." "I've lost my phobia of water." "I'm not losing my temper as much." "I'm sleeping better and don't have nightmares."
"I'm sleeping better and don't have nightmares."
A client, age 40, is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse comes to take her to surgery, she is tearfully finishing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? "Try to take a few deep breaths and relax. I have some medication that will help." "I can understand that you're nervous, but this is really a minor procedure. You'll be back in your room before you know it." "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours." "In case anything goes wrong? What are your thoughts and feelings right now?"
"In case anything goes wrong? What are your thoughts and feelings right now?"
A nurse is caring for a client who has recently returned from military service overseas. The client has a history of explosive anger, unemployment, and depression since returning home. The client reports feeling ashamed of being "weak" and letting past experiences control thoughts and actions. Which response from the nurse would be best? "Many people who have been in your situation experience similar emotions and behaviors." "No one can predict how he'll react in a traumatic situation." "Weak people don't want to make changes in their lives." "It's not too late for you to make changes in your life."
"Many people who have been in your situation experience similar emotions and behaviors."
A woman, age 18, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with functional neurologic symptom disorder. The client asks the nurse, "Why has this happened to me?" What is the most appropriate response? "You've developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again." "It isn't uncommon for someone with your personality to develop this disorder during times of stress." "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."
"Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."
The nurse refers a client with severe anxiety to a psychiatrist for medication evaluation. The nurse expects the physician is most likely to prescribe which psychotropic drug regimen for this client? Chlorpromazine, 25 mg orally three times per day Buspirone, 5 mg orally three times per day Clozapine, 200 mg orally twice per day Benztropine, 2 mg orally twice per day
Buspirone, 5 mg orally three times per day
During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The client is pale with his mouth wide open and eyebrows raised. What should the nurse do first? Set limits for acting out delusional behaviors. Administer an I.M. anxiolytic agent. Assist the client to breathe deeply into a paper bag. Orient the client to person, place, and time.
Assist the client to breathe deeply into a paper bag.
The nurse in a psychiatric inpatient unit is caring for a client with obsessive-compulsive disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should instruct the client to follow which advice? Maintain an adequate salt intake Stay out of the sun Avoid caffeine Avoid aged cheeses
Avoid caffeine
The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority? Respect the client's personal space. Decrease environmental stimuli. Encourage the client to discuss feelings. Provide for the client's safety needs.
Provide for the client's safety needs.
