Stress and Coping Questions

28) A client who has been divorced for 1 year begins to take classes at a community college and has enrolled the children in daycare. When documenting the client's actions, which phrase is the most appropriate for the nurse to use? A) Turning point in life B) Maturational crisis C) Situational crisis D) Responding to stress

Answer: A Explanation: A) Crisis situations such as a divorce can become turning points or junctures in life that result in a change in equilibrium, positive or negative. The client may have experienced a situational crisis and stress, but the events of the client's last year have resulted in a turning point. A maturational crisis is a developmental progression to the next level of maturity, a predictable event experienced by nearly all individuals.

3) A client worries every day about personal health and states, "I may not have enough medication if the weather takes a turn for the worse." Based on this data, which diagnosis does the nurse anticipate for this client? A) Generalized anxiety disorder B) Phobia C) Obsessive-compulsive disorder D) Panic disorder

Answer: A Explanation: A) Generalized anxiety disorder is excessive worry about everyday problems, with the anxiety being more intense than the situation warrants. The client is demonstrating signs of generalized anxiety disorder. A phobia is an intense, persistent, irrational fear of a simple thing or social situation that compels the individual to avoid the stressor that elicits the fear. Panic disorder is a sudden attack of terror, accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive repetitive behaviors formed in response to the obsessive thoughts to lower the level of anxiety experienced.

19) Which is the priority nursing action when providing care to a client who demonstrate signs of escalating anxiety? A) Isolate the client in a safe, quiet, and protective environment. B) Leave the client alone in a room. C) Provide a benzodiazepine. D) Phone the physician.

Answer: A Explanation: A) The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.

15) While attempting to choose a nursing diagnosis, the nurse must decide whether a client is experiencing anxiety or fear. Which key point would allow the nurse to plan care based on the nursing diagnosis of Anxiety? A) The source of fear is identifiable, but anxiety may be vague. B) Anxiety is a milder form of fear. C) Fear results in a physiologic response, whereas anxiety is psychological. D) Anxiety is generally based in reality, whereas fear is not.

Answer: A Explanation: A) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a milder form of fear.

9) The nurse is assessing a client who demonstrates physiologic manifestations of a stress response. Which physiologic manifestations result for the inhibition of the parasympathetic nervous system? Select all that apply. A) Dry oral mucous membranes B) Hypoactive bowel sounds C) Increased heart rate D) Increased respiratory rate E) Increased depth of respirations

Answer: A, B Explanation: A, B) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.

20) The nurse is admitting a client with panic anxiety to the behavioral health unit. Which clinical manifestations would indicate that the client's anxiety is at a panic level of severity? Select all that apply. A) Inability to focus B) Dilated pupils C) Feelings of doom D) Self-absorption E) Rapid speech

Answer: A, B, C Explanation: A, B, C) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.

26) Which nursing diagnoses would be applicable for a client who is experiencing a situational crisis? Select all that apply. A) Ineffective Coping B) Risk for Self-Directed Violence C) Spiritual Distress D) Risk for Loneliness

Answer: A, B, C Explanation: A, B, C) Loneliness may result from an individual's actions following a crisis, but it is not an appropriate nursing diagnosis for situational crisis. The other three answers are among the most common nursing diagnoses for people in crisis.

31) A nurse is caring for a client in crisis. While providing care it is imperative that the nurse communicates effectively with this client. Which is true when communicating with clients in crisis? Select all that apply. A) Communication should be frequent. B) Communication should be brief. C) Communication should be simple. D) Communication should be detailed. E) Communication should be directive.

Answer: A, B, C, E Explanation: A, B, C, E) Communicating with individuals in crisis requires frequent, brief, simple, and often directive communication. Biologically speaking, the brain of the individual in crisis is in the process of being bombarded with electrochemical reactions. Concentration and the ability to remember and retain information can be impaired.

36) A client witnessed a violent bank robbery. Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder? Select all that apply. A) Fear of returning to sleep B) Excessive sleeping C) Terrifying nightmares D) Aggressive behavior E) Hair pulling

Answer: A, C, D Explanation: A, C, D) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.

29) The nurse is beginning crisis counseling with a client. What actions will the nurse utilize when counseling the client? Select all that apply. A) Assist in coping with the problem. B) Conduct follow-up assessments. C) Boil down the problem. D) Achieve contact. E) Assess physiologic status.

Answer: A, C, D Explanation: A, C, D) When conducting crisis counseling with a client, the nurse will achieve contact, boil down the problem, and assist the client in coping with the problem. Assessing physiologic status and conducting follow-up assessments are not steps within crisis counseling.

18) The nurse is instructing a client with an anxiety disorder on behavioral tools to help with coping. Which tools to help with coping should the nurse include in the teaching session? Select all that apply. A) Reading self-help literature B) Thought stopping C) Journaling D) Distraction E) Practicing yoga

Answer: A, C, E Explanation: A, C, E) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.

35) The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply. A) Observed family member be raped and murdered B) Restores antique automobiles as a hobby C) Lives with spouse and has a garden D) Has a history of anxiety disorder E) Recently terminated from employment

Answer: A, D, E Explanation: A, D, E) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.

4) Which assessment findings indicate to the nurse that a client is experiencing stress? Select all that apply. A) Chewing on a finger nail B) Checking cellular phone C) Reading a magazine D) Talking with others E) Tapping foot

Answer: A, E Explanation: A, E) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.

12) A client, who is experiencing slight anxiety, is trembling and communicating in a manner that makes it difficult for the nurse to understand the client's needs. Based on this data, which level of anxiety is the client likely experiencing? A) Panic B) Severe C) Moderate D) Mild

Answer: B Explanation: B) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand and trembling can occur. Communication may not be understandable at all when the client reaches the panic stage.

34) During the assessment, the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang. Which should the nurse assume regarding the client's behavior? A) The client thought there was an earthquake. B) The client was reacting to the loud noise as a form of a flashback. C) The client wanted to check the cause for the loud noise. D) The client thought the assessment was concluded.

Answer: B Explanation: B) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.

17) The nurse is evaluating medication teaching for a client who recently started taking fluoxetine (Prozac) for anxiety. Which statement by the client indicates appropriate understanding of the information presented? A) "My medication will take 1 week to become effective." B) "My medication will take 4 weeks to become effective." C) "My medication will become effective immediately after I start taking it." D) "My medication will not begin to work for 12 weeks."

Answer: B Explanation: B) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12 weeks to see a full response to the drug.

23) The nurse is providing care to a client who is "in crisis." The client recently lost a job, was served with divorce papers, and has been sick with a cold for 1 month. Which nursing statement demonstrates understanding of the care of a client in crisis? A) "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible." B) "People generally find it easier to work through a crisis if someone is working with them." C) "Men often handle crisis better individually, whereas women do better with a counselor." D) "Once you reach the crisis state, you may remain there for several months until you recover."

Answer: B Explanation: B) In general, people are more successful in working through a crisis if they have someone to help them. This need for help is not gender dependent. A crisis results in such a state of disequilibrium that it is generally self-limiting and not a long-term event. Experiencing a crisis may actually offer the family or individual a potential for growth and change.

5) The nurse suspects that a healthy client could be experiencing stress because of which laboratory result? A) Serum sodium of 142 mEq/L B) Serum glucose of 165 mg/dL C) Serum potassium of 4.0 mEq/L D) Serum calcium of 10.2 mEq/L

Answer: B Explanation: B) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and more accurate. However, they may be necessary to rule out medical conditions that can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing stress because of an increase in adrenal function. One physiological indicator of stress is an increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The other laboratory values are within normal limits.

27) When planning interventions to address a client's crisis, which actions by the nurse are appropriate? A) Develop the plan prior to meeting with the client. B) Conduct a complete assessment. C) Determine follow-up. D) Focus on long-term problems.

Answer: B Explanation: B) Nursing care is based on assessment. Thus, a plan cannot be developed prior to meeting with the client. The time frame, whether short term or long term, and the need for follow- up will be determined by the findings of the assessment.

42) A client is admitted with a diagnosis of post-traumatic stress disorder (PTSD). During a review of the client's history, the nurse is made aware that the client suffers from depression and suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely irritable and that the main reason he is there is because he has been having frequent nightmares. Based on the assessment findings, which medication prescription does the nurse anticipate for this client? A) Propanolol (Inderal) B) Prazosin (Minipress) C) Risperidone (Risperdal) D) Fluvoxamine (Luvox)

Answer: B Explanation: B) Prazosin is an antihypertensive medication that may be prescribed for treatment and prevention of nightmares. Propanolol (Inderal) is a beta-blocker; its possible uses include management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an antipsychotic that may be used in the treatment of OCD or panic disorders. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of OCD.

7) Which intervention would help a client who is demonstrating stress about being hospitalized and concerned about the needs of the children at home? A) Ask the client if there is anything that is needed once discharged to home. B) Ask the client if there is anyone who would be able to help with the family needs at home during recuperation. C) Find out if the children can be sent to a grandparent's home until the client fully recovers. D) Suggest the client be transferred to a long-term care facility to ensure a full recovery.

Answer: B Explanation: B) The best way that the nurse can help the client who is stressed with a new illness and family responsibilities is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent's home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.

6) A client complains about the stress of having to work long hours and missing daily exercise routines. Which response by the nurse is appropriate? A) "There are other ways to reduce stress, such as meditation." B) "Exercise helps reduce the impact of stress on the body and would be a good thing." C) "Drinking a small glass of wine each day does help reduce stress." D) "Maybe exercising, with all of the work, would be too much for your body anyway."

Answer: B Explanation: B) The client had been exercising but has not because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client's not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest using alcohol to deal with stress.

2) A client states to the nurse that learning how to use the blood glucose machine will have to wait until holiday events are planned. Which cognitive indication of stress is the client demonstrating? A) Problem solving B) Suppression C) Self-control D) Structuring

Answer: B Explanation: B) The client is demonstrating suppression, which is the conscious and willful act of putting a thought or feeling out of mind. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or manipulation of a situation so that threatening events do not occur. Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge.

16) Which nursing intervention minimizes the stress and anxiety of hospitalization for a client? A) Explain all procedures in detail before performing them. B) Control the environment of healing. C) Demonstrate staff competence by using multiple nurses for care. D) Let the client make the majority of decisions about the plan of care.

Answer: B Explanation: B) The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.

38) The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago. Which should the nurse include in the client's plan of care? A) Guidelines on conducting activities of daily living B) Information on the treatments available C) Referral to local employment agency D) Information on the need for adequate exercise

Answer: B Explanation: B) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.

24) After an assessment, the nurse determines that an older adolescent client is experiencing a maturational crisis because of which findings? Select all that apply. A) Relationship with significant other ended B) Inability to focus on school studies C) Cannot sleep at night and skips classes D) Recent death of a friend E) Graduating from high school in 2 months

Answer: B, C, E Explanation: B, C, E) Senior year is a transition to work or college. This is a developmental progression to the next level of maturity, a predictable event experienced by nearly all individuals. The client is demonstrating stressors unique to progressing to the next level of maturity. The recent death of a friend and having a relationship with a significant other end are situational crises.

39) The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder. Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply. A) The client takes a sedative at least 4 times a day. B) The client has been sleeping throughout the night. C) The client keeps all of the lights on at home. D) The client verbalizes future plans with family and friends. E) The client will not enter a car with fewer than three people.

Answer: B, D Explanation: B, D) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.

25) Which are appropriate responses by the nurse when providing care for a client who is experiencing a situational crisis? Select all that apply. A) "I know just how you feel." B) "I am sorry this happened to you." C) "It's best to stay busy." D) "Things will get better and you will feel better." E) "It could have been worse."

Answer: B, D Explanation: B, D) Stating that the nurse is sorry for what the client has experienced reflects empathy. Saying that things will get better and the client will feel better provides hope. Assessing the client's current emotional state and coping mechanisms that have been effective in the past requires open-ended questions and attentive listening. Stating that the nurse knows how the client feels hinders this communication and takes the focus off the client. Telling the client to stay busy does not empower the client to identify and adopt coping strategies. Telling the client it could have been worse minimizes the client's unique experience.

30) ) The nurse is working with a family who survived a tornado. As part of providing care to the family, the nurse is reviewing normal reaction and emotions they may experience as a result of the traumatic event. Which conclusions does the nurse make? Select all that apply. A) All family members will process the experience at about the same pace. B) Each member of the family has a different way of coping. C) Each family member talks to the nurse openly and freely. D) All family members will experience anxiety about self and family safety. E) Some family members have difficulty accepting help.

Answer: B, D, E Explanation: B, D, E) Anxiety about self and family's safety is an initial reaction after an individual's safety has been in jeopardy. Each member of the family has a different way of coping. Family members are all at different levels of maturity and have different coping skills. Some family members have difficulty accepting help. Different family members will respond in various ways to offers of help due to each person's individuality and coping style. Communication is difficult for most clients after a sudden crisis, so it is unlikely that they will talk to the nurse openly and freely. All family members will process the experience at about the same pace is incorrect because family members' different maturity levels and coping skills will affect how quickly or slowly they process the experience.

40) A client diagnosed with posttraumatic stress disorder is experiencing insomnia. Which interventions would be beneficial for this client? Select all that apply. A) Discuss the importance of exercise before sleep. B) Instruct in relaxation techniques. C) Encourage the use of sedatives. D) Suggest daytime naps. E) Coach in the use of guided imagery.

Answer: B, E Explanation: B, E) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation techniques and guided imagery are just two therapies found to be beneficial in clients with this disorder. Daytime naps are to be avoided. Sedatives do not produce long-term relief from insomnia and should not be encouraged. Exercise before sleep would serve as a stimulant and should not be encouraged.

41) Which nursing interventions would be appropriate for a client demonstrating acute anxiety related to posttraumatic stress disorder? Select all that apply. A) Encourage the client to discuss what caused the syndrome to develop. B) Provide a calm, quiet environment. C) Give the client paperwork to complete while waiting to be assessed. D) Ask the client what is causing the anxiety. E) Reassure the client that the environment is safe.

Answer: B, E Explanation: B, E) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of his or her safety. The client should not be given paperwork to complete. Asking the client what is causing the anxiety and encouraging the client to discuss what caused the syndrome to develop are not effective interventions for acute anxiety related to this disorder and should not be done.

21) A nurse on the behavioral health unit is leading a group regarding risk factors for anxiety. At the completion of group work, which comment made by a client would indicate the need for further teaching? A) "A lack of social interaction places me at risk for anxiety." B) "My personality could place me at risk for anxiety because I am shy." C) "Chronic illness is not a risk factor unless I am also unemployed." D) "I experienced a traumatic event that placed me at risk for having this anxiety disorder."

Answer: C Explanation: C) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.

1) After a mammogram, a client is told that she needs a fine needle aspirate of a breast mass. Which actions by the client demonstrates engagement in a primary appraisal of the stressful situation? A) Holding her breath while the nurse is talking B) Sitting in the dressing room and cries C) Asking the nurse if she has cancer D) Scheduling the procedure in 6 weeks, which is the earliest possible appointment

Answer: C Explanation: C) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.

14) While caring for a critically ill child, the child's mother becomes distraught and begins to cry loudly while stroking the child's face. Which is the best response by the nurse? A) Explain the procedure that will occur with the treatment. B) Tell the mother that she needs to control herself for the benefit of her child. C) Take the mother out of the room and comfort her. D) Distract the mother by having her straighten the linens on the bed.

Answer: C Explanation: C) In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.

11) A nurse on the behavioral health unit is caring for a client diagnosed with depression, who just lost a spouse in a motor-vehicle accident. The client states to the nurse, "my wife would not have wanted to live if she were disabled." Based on this statement, which defense mechanism is the client using? A) Identification B) Denial C) Intellectualization D) Displacement

Answer: C Explanation: C) Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.

13) A client, who was recently being laid off from work, is scheduled for a biopsy to detect a malignancy. When planning this client's care, which does the nurse include? A) Reasons to delay the biopsy B) Medicate around the clock for pain C) Interventions to address anxiety D) Social services to aid with financial planning

Answer: C Explanation: C) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client's financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.

22) The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client would indicate to the nurse a need for further education? A) "This medicine could make me feel like I have the jitters." B) "I may experience some nausea while on this medication." C) "My doctor will start me off on a high dose and then decrease the dose." D) "This medicine alters the levels of the neurotransmitter serotonin in the brain."

Answer: C Explanation: C) SSRIs are generally started at low doses and then increased as their effectiveness becomes apparent; therefore this statement made by the client is inaccurate and does indicate a lack of understanding and the need for further teaching. The other statements are accurate so do not require further teaching.

38) A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman. Which nursing diagnosis is most appropriate for this client? A) Fear B) Anxiety C) Post-Trauma Syndrome D) Ineffective Coping

Answer: C Explanation: C) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.

33) The nurse is providing care to a client who is experiencing a crisis. Which statement by the client indicates that the goals of care have not been met? A) "I came up with some ideas on how to cope when I am in this position." B) "I feel like I am in control and can begin managing things now." C) "I am not sure whom I am going to call when I start feeling like this again." D) "I can deal with this, I am a strong person, and I have a lot of friends and family."

Answer: C Explanation: C) The client who is unsure of who to call in a crisis has not met goals yet. The other statements demonstrate a good understanding of managing a crisis.

32) A clinic nurse is assessing a client who is experiencing crisis. The nurse needs to determine the client's immediate needs. Which is the priority action by the nurse? A) Scan for physical distress. B) Explore perceptions of the crisis. C) Develop a follow-up plan. D) Assess for immediate safety needs.

Answer: D Explanation: D) Assessing for immediate safety needs would take priority. An example of this would be a client coming into the clinic in crisis because she was violently abused by a significant other. It would be imperative for the nurse to determine the immediate safety needs of the client before proceeding. Scanning for physical distress and exploring perceptions of the crisis are important, but do not take priority over safety. Developing a follow-up plan would occur only after other interventions have been implemented.

43) A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD). The client was recently admitted to the hospital for suicide ideations and sleep disturbance due to frequent nightmares. Which is the priority goal to include in the client's plan of care? A) The client will report a reduction in or cessation of nightmares. B) The client will report a decreased perception of anxiety. C) The client will discuss emotions related to traumatic experiences. D) The client will remain free from injury or harm.

Answer: D Explanation: D) Assuring that the client remains free of injury would be the priority goal. The client was admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety is a priority. The other goals are relevant to the care of the client; however, they are not the priority goals.

44) A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder (PTSD) who was admitted to the hospital for suicide ideations and sleep disturbance due to frequent nightmares. Which is the priority nursing diagnosis for this client? A) Disturbed Sleep Pattern B) Post-Trauma Syndrome C) Risk for Other-Directed Violence D) Risk for Self-Directed Violence

Answer: D Explanation: D) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be the priority nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or harming others; therefore Risk for Other-Directed Violence would not be appropriate for this client.

8) Which instruction by the nurse to a client prescribed diazepam (Valium) for anxiety and stress is appropriate? A) "This medication will be good to take for a long time." B) "Take this medication every time feelings of stress become overwhelming." C) "This medication works best if taken with a meal." D) "This medication is good to use for the short term only."

Answer: D Explanation: D) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client's anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.

10) A client is recently prescribed risperidone (Risperdal) by the healthcare provider. Which would be a priority nursing consideration for this client? A) Assess blood pressure and heart rate. B) Monitor for increased agitation. C) Assess for drowsiness. D) Monitor for neuroleptic syndrome.

Answer: D Explanation: D) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.