Deck 2 Module 31

Question 1

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 1

B) Serum glucose of 165 mg/dL

Rationale:

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.

Question 2

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 2

A) Dry oral mucous membranes
B) Hypoactive bowel sounds

Rationale:

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.

Question 3

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 3

B) Severe

Rationale:

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.

Question 4

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 4

C) Interventions to address anxiety

Rationale:

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.

Question 5

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 5

C) Take the mother out of the room and comfort her.

Rationale:

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.

Question 6

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 6

A) The source of fear is identifiable, but anxiety may be vague.

Rationale:

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.

Question 7

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 7

B) Control the environment of healing.

Rationale:

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.

Question 8

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 8

B) “I am sorry this happened to you.”
D) “Things will get better and you will feel better.”

Rationale:

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.

Question 9

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 9

A) Ineffective Coping
B) Risk for Self-Directed Violence
C) Spiritual Distress

Rationale:

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.

Question 10

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 10

B) Conduct a complete assessment.

Rationale:

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.

Question 11

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 11

A) Turning point in life

Rationale:

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.

Question 12

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 12

B) Each member of the family has a different way of coping.
D) All family members will experience anxiety about self and family safety.
E) Some family members have difficulty accepting help.

Rationale:

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.

Question 13

A parent says to the nurse, "I think my son is showing signs of obsessive-compulsive disorder, just like my father." Which risk factors in the client’s medical history would support this diagnosis? 
Select all that apply.
A) Lives with parents
B) Male gender
C) Unemployed
D) History of chronic illnesses
E) Family history

Answer 13

B) Male gender
E) Family history

Rationale:

Risk factors for obsessive-compulsive disorder include a family history and a major life stressor. Men develop the disorder earlier, between the ages of 6 and 15. Living with parents, being unemployed, or having a history of chronic illnesses are not risk factors for the disorder.

Question 14

The son of an older adult client with obsessive-compulsive disorder states to the nurse, “I want to contact the fire department about the situation; the house is nothing but boxes and bags of saved items.” Which is the most appropriate nursing diagnosis for this situation?
A) Ineffective Coping
B) Deficient Knowledge
C) Risk for Caregiver Role Strain
D) Anxiety

Answer 14

C) Risk for Caregiver Role Strain

Rationale:

The son is experiencing anxiety about the client’s obsessive-compulsive behavior, which indicates a risk for caregiver role strain. There is not enough information to determine whether or not the client or son is experiencing ineffective coping, anxiety, or deficient knowledge.

Question 15

A client asks for a hospital bed near the door because of a fear of being trapped in a room and not being able to get out. When planning care for this client, which does the nurse include as a possible cause for this client’s fear? 
A) Genetic predisposition
B) A traumatic event
C) Observing others
D) Informational transmission

Answer 15

B) A traumatic event

Rationale:

Factors that predispose an individual to develop phobias, such as the fear of not getting out of a room, include traumatic events. Genetic predisposition would mean that others in the client’s family have the same fear. Informational transmission means the fear would be explained or demonstrated through the media. Observing others would mean that the client has seen others demonstrate the same fear of not being near the door.

Question 16

Which is the role of the nurse when providing care to a client diagnosed with a phobia?
A) Providing comfort and alleviating emotional distress
B) Encouraging the client to confront fears
C) Providing medication to help reduce the symptoms of the disorder
D) Telling the client that the hospital is a safe place

Answer 16

A) Providing comfort and alleviating emotional distress

Rationale:

The role of the professional nurse caring for clients with phobic disorders is to provide comfort to the client and family and alleviate emotional distress. The nurse supports adaptive coping while empowering the client by providing information, accessing resources, and communicating therapeutically. The nurse should not encourage the client to confront fears or tell the client that the hospital is a safe place. The client may or may not be prescribed medication for the disorder.

Question 17

The nurse is providing teaching to a client diagnosed with a social phobia. Which client statement indicates appropriate understanding of the information presented?
A) “I try to avoid all situations where I am expected to talk in front of other people.”
B) “I can control anxiety by deep breathing and relaxing before talking in front of other people.”
C) “I take an antianxiety pill before I have to do anything in front of other people.”
D) “I can have a drink before I speak in front of other people.”

Answer 17

B) “I can control anxiety by deep breathing and relaxing before talking in front of other people.”

Rationale:

People with social phobias may medicate themselves with alcohol or drugs to make it possible to endure social situations. This is not evidence that teaching has been effective. The individual with a social phobia may also avoid all situations in which the phobia occurs. This is also not evidence of successful instruction. Learning to control anxiety by deep breathing and relaxation is evidence that instruction about social phobias has been successful.

Question 18

A client wants to visit family members who live in Asia but has a fear of flying. Which strategy is an appropriate treatment option for this client? 
A) Cognitive restructuring
B) The use of antianxiety medication
C) Meditation
D) Physical exercise

Answer 18

A) Cognitive restructuring

Rationale:

Cognitive restructuring is based on the belief than anxiety stems from erroneous interpretations of situations. The client learns to reframe or relabel a frightening situation or activity so that it becomes less threatening. Meditation helps with relaxation. The use of antianxiety medication will not help the client learn how to cope with the anxiety associated with flying. Physical exercise does not directly deal with cognition.

Question 19

A client is experiencing severe anxiety associated with a phobia. Which nursing actions are appropriate when providing care to the client?
Select all that apply.
A) Explain why the reaction to the phobia is unrealistic.
B) Make sure the client understands that she is safe.
C) Teach why the phobia is imagined.
D) Coach the client to deep breathe.
E) Ensure a quiet and calm environment

Answer 19

B) Make sure the client understands that she is safe.
E) Ensure a quiet and calm environment.

Rationale:

As a client’s anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.

Question 20

A nurse educator is teaching a group of new staff members recently hired on a behavioral health unit. Which examples of cognitive-behavioral therapy (CBT) does the educator include as expected when providing care to clients on the unit? 
Select all that apply.
A) Cognitive restructuring
B) Relaxation techniques
C) Systematic desensitization
D) Reciprocal inhibition
E) Benzodiazepine administration

Answer 20

A) Cognitive restructuring
C) Systematic desensitization
D) Reciprocal inhibition

Rationale:

Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.

Question 21

The nurse is providing care to several clients at an outpatient clinic. Which client is at the greatest risk for developing a social anxiety disorder? 
A) 11-year-old boy
B) 14-year-old girl
C) 26-year-old female
D) 30-year-old male

Answer 21

B) 14-year-old girl

Rationale:

A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.

Question 22

The nurse is evaluating the care plan for a client diagnosed with agoraphobia. Which client statement indicates the goals of treatment have been met?
A) “I will be able to make it to my outpatient appointments as long as I can find someone to go with me. It is just easier if I ride with someone.”
B) “I can’t participate in counseling once I get discharged because I hate to leave the house if I don’t have to. Other people hate to leave their house for no reason.”
C) “It is not going to be easy but I will be making it to my appointments even if I have to leave the house by myself. I have been practicing and deep breathing exercises are helping.”
D) “Every time I try to leave the house I panic and I feel like passing out. I just don’t know how this is going to get any better.”

Answer 22

C) “It is not going to be easy but I will be making it to my appointments even if I have to leave the house by myself. I have been practicing and deep breathing exercises are helping.”

Rationale:

The client who acknowledges that leaving the home alone is difficult but is committed to keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing healthy ways of responding to the fear. The other statements indicate that the client has not met an appropriate goal in responding to the fear.

Question 23

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 23

B) The client was reacting to the loud noise as a form of a flashback.

Rationale:

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.

Question 24

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 24

A) Observed family member be raped and murdered
D) Has a history of anxiety disorder
E) Recently terminated from employment

Rationale:

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.

Question 25

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

Answer 25

A) Fear of returning to sleep
C) Terrifying nightmares
D) Aggressive behavior

Rationale:

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.

Question 26

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 26

C) Post-Trauma Syndrome

Rationale:

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.

Question 27

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 27

B) Information on the treatments available

Rationale:

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.

Question 28

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 28

B) The client has been sleeping throughout the night.
D) The client verbalizes future plans with family and friends.

Rationale:

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.

Question 29

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 29

B) Instruct in relaxation techniques.
E) Coach in the use of guided imagery.

Rationale:

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.

Question 30

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 30

B) Provide a calm, quiet environment.
E) Reassure the client that the environment is safe.

Rationale:

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.

Question 31

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 31

B) Prazosin (Minipress)

Rationale:

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.

Question 32

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 32

D) The client will remain free from injury or harm.

Rationale:

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.

Question 33

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 33

D) Risk for Self-Directed Violence

Rationale:

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.