A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

Recommend that the client avoid driving over the bridge.

Teach the client to listen to music or audio books while driving.

Tell the client to drive over the bridge until fear is manageable.

Encourage the client to have the spouse drive in stressful places.

Answer and Explanation

The Correct Answer is B

A. Recommend that the client avoid driving over the bridge: Avoidance reinforces the anxiety and prevents the client from developing effective coping mechanisms. Over time, this may worsen the phobia and reduce the client’s functional independence and quality of life.

B. Teach the client to listen to music or audio books while driving: Calming distractions can help reduce anxiety symptoms and promote gradual exposure to the feared situation. This approach supports desensitization while helping the client stay in control and manage symptoms.

C. Tell the client to drive over the bridge until fear is manageable: Flooding, or forced prolonged exposure, may overwhelm the client and worsen anxiety. A more gradual, supportive approach is generally safer and more effective in treating specific and anxiety.

D. Encourage the client to have the spouse drive in stressful places: Delegating driving to someone else may provide short-term relief, but it limits the client’s independence and does not promote long-term coping or resolution of the anxiety trigger.

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Correct Answer is C

Explanation

A. Type of anticonvulsant prescribed: While the class or type of anticonvulsant influences seizure control, it does not directly indicate whether the client is receiving a sufficient dosage. The therapeutic effectiveness depends more on blood concentration than classification.

B. History of a recent illness: Acute illness can temporarily lower the seizure threshold, but it is a less specific indicator for predicting recurrence than pharmacologic control. The underlying condition must be assessed, but medication levels are more predictive of seizure risk.

C. Therapeutic level of medication: A subtherapeutic drug level is a strong predictor of seizure recurrence. Maintaining an adequate plasma concentration ensures optimal seizure control and is crucial in clients recovering from status epilepticus, where precise management is essential.

D. Duration of previous seizure activity: The length of the prior seizure can indicate severity but not the likelihood of recurrence. Even brief seizures can recur if anticonvulsant levels are inadequate, so duration is not as clinically useful as drug level monitoring.

Correct Answer is []

Explanation

Rationale for Correct Choices:

Bowel obstruction: The client's symptoms are classic signs of a bowel obstruction. Additionally, the lab results showing elevated sodium (165 mEq/L), low potassium (3.2 mEq/L), and low bicarbonate (20 mEq/L) suggest an electrolyte imbalance often seen in bowel obstructions due to fluid loss and impaired bowel function.
Insert nasogastric tube: A nasogastric tube is commonly used in bowel obstruction to decompress the stomach, relieve vomiting, and prevent aspiration. It helps reduce abdominal distention and allows for drainage of the stomach contents.
Maintain NPO status: Maintaining NPO status is essential in bowel obstruction to prevent further complications such as aspiration, vomiting, or perforation. It also helps to prepare the client for possible surgery if needed and allows the bowel to rest.
Signs and symptoms of sepsis: Given the possibility of bowel perforation or ischemia in a bowel obstruction, monitoring for signs and symptoms of sepsis is crucial. Fever, tachycardia, and hypotension could indicate the onset of systemic infection due to bowel perforation or necrosis.
Strict intake and output: Monitoring strict intake and output is vital to assess for dehydration or fluid imbalance, which can occur due to vomiting, diarrhea, or poor oral intake in bowel obstructions. Accurate monitoring helps guide treatment and fluid resuscitation.

Rationale for Incorrect Choices:

Pancreatitis: Pancreatitis presents with severe upper abdominal pain that may radiate to the back, nausea, vomiting, and sometimes jaundice. There are no signs like elevated lipase or amylase levels to suggest pancreatitis.
Food poisoning: Food poisoning can cause nausea, vomiting, and diarrhea, but it usually has an acute onset and resolves within a short period (usually a day or two). This child's symptoms have persisted for two days, and there is no mention of fever or diarrhea.
Ruptured gallbladder: A ruptured gallbladder would present with severe right upper quadrant pain, fever, and jaundice due to bile leakage or infection. There is no indication of right upper quadrant pain or jaundice in this child.

Culture emesis: While culturing emesis may be useful in diagnosing foodborne illnesses or infection, it is not necessary in a case of bowel obstruction. The primary intervention in bowel obstruction is relieving the obstruction and monitoring for complications.
Prep for immediate gallbladder removal: Cholecystectomy is not indicated in this case. The client’s symptoms are not characteristic of gallbladder issues like cholecystitis or gallstone complications. The focus should be on diagnosing and managing the bowel obstruction.
Administer oxygen via face mask: Oxygen administration is typically indicated in cases of respiratory distress or shock. While this client is experiencing discomfort, she is not showing signs of hypoxia or severe circulatory issues. Spo2 is 97% indicating adequate saturation.

Bilirubin levels: Bilirubin levels are typically monitored when jaundice or liver dysfunction is suspected. This client does not show signs of jaundice or liver disease, and her symptoms are more consistent with a bowel obstruction.
Rebound tenderness: Rebound tenderness is useful in cases of peritonitis or bowel perforation. However, the absence of guarding and the fact that the child is not exhibiting acute peritonitis symptoms makes rebound tenderness less relevant.
Arterial blood gas (ABG): ABG measurements are typically used to assess respiratory and metabolic function. While the electrolyte imbalances seen in this patient (e.g., low bicarbonate) could suggest mild acidosis, ABG testing is not immediately necessary unless the client shows signs of severe metabolic disturbance or shock.

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A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A client who is admitted after an episode of status epilepticus is stabilized. Which finding should the nurse use to determine the client's risk for recurrence of seizure activity?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

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