A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Establish trust by providing a calm, safe environment.

Encourage deep breathing when anxiety escalates in a crowd.

Progressively expose the client to larger crowds.

Encourage substitution of positive thoughts for negative ones.

Answer and Explanation

The Correct Answer is A

A.   Establishing trust by providing a calm, safe environment is crucial for clients with agoraphobia, as it lays the foundation for effective therapeutic interventions and supports the client's sense of safety and security.
B.   Encouraging deep breathing is a helpful coping strategy, but it may not be the highest priority compared to establishing trust and safety.
C.   Progressively exposing the client to larger crowds is part of desensitization therapy, but it should be done gradually and only after trust and rapport have been established.
D.   Encouraging substitution of positive thoughts for negative ones is a valuable cognitivebehavioral technique, but it may be more effective once the client feels safe and supported in the therapeutic environment.

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Correct Answer is C

Explanation

A. While a history of heart disease is important to consider, it is not the most crucial information to obtain prior to administering sertraline.
B. Familial history of mental illness is relevant but may not directly impact the immediate administration of sertraline.
C. Obtaining a thorough medication history is essential to identify potential drug interactions, allergies, or contraindications that could affect the safety and efficacy of sertraline.
D. While current weight may influence the dosing of certain medications, it is not typically a primary consideration prior to administering sertraline.

A. Episodic intervals of pruritus. B. Erythema of the localized lesions. C. Ecchymotic blood accumulations. D. Evidence of patches of lost hair.

Correct Answer is C

Explanation

A. Episodic intervals of pruritus (itching) may suggest a dermatological condition or irritation of the scalp, but they do not directly indicate that the hair loss is not disease-related.
B. Erythema (redness) of the localized lesions may suggest inflammation or irritation but does not necessarily indicate that the hair loss is not disease-related.

C. Ecchymotic blood accumulations (bruising) suggest trauma or repeated pulling at the hair, which is not typically associated with disease-related causes. This finding can indicate a behavioral issue, such as trichotillomania (a compulsive hair-pulling disorder), where physical damage to the scalp can result in bruising and bald patches. The presence of ecchymosis supports a mechanical, non-disease-related cause of hair loss.

D. Evidence of patches of lost hair alone does not confirm whether the hair loss is disease-related or non-disease-related. Patches of hair loss can occur with both behavioral conditions (e.g., trichotillomania) and diseases (e.g., alopecia areata, fungal infections).

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A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

Correct Answer is C

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

Correct Answer is C

Explanation

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