A nurse is caring for a client who was recently admitted.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Moderate anxiety: The client's symptoms, including irritability, restlessness, and a preoccupation with their thoughts (e.g., talking about "nice" clothes and the collection of toy cars), are more indicative of anxiety. The elevated heart rate and restlessness support this, as anxiety often causes physical symptoms like increased heart rate and difficulty focusing.
Encourage the client to engage in physical activity: Physical activity helps reduce anxiety by promoting relaxation and offering an outlet for nervous energy. It can assist in reducing the client's restlessness and help manage anxiety symptoms.
Encourage the client to problem solve: Anxiety often stems from feeling overwhelmed or out of control. Encouraging the client to problem-solve can help them feel more in control of their thoughts and reduce anxiety by breaking down issues into manageable steps.
Heart rate: An elevated heart rate of 116 beats per minute is a common physiological response to anxiety. Monitoring heart rate helps gauge the severity of the client's anxiety and whether interventions are effective in managing it.
Ability to focus on the task at hand: Anxiety often causes difficulty with concentration and focus, so assessing the client's ability to maintain attention can help determine the impact of their anxiety and the effectiveness of interventions.

Rationale for incorrect choices:

Hoarding disorder: Although the client exhibits an interest in items from their childhood, there is no indication that they are accumulating items uncontrollably or have difficulty discarding things.
Body dysmorphic disorder: While the client is focused on body image ("looking fit"), there is no evidence of extreme preoccupation with perceived flaws or a distorted view of their appearance, which is central to body dysmorphic disorder.
Obsessive-compulsive disorder: Although the client is fidgeting and restless, these behaviors are more likely linked to anxiety rather than compulsions or rituals associated with OCD. The behavior doesn't suggest the obsessive, ritualistic patterns seen in OCD.
Evaluate the client's ability to make decisions about their accumulated items: This action is more relevant for hoarding disorder. There is no indication that the client is accumulating items in an uncontrolled manner.
Allow time for the client to complete ritualistic behavior: This is a strategy for OCD, where individuals feel compelled to complete specific rituals. The client's behavior is more related to anxiety and restlessness, not compulsive rituals.
Observe the client's focus on body image: While the client seems to care about their appearance, there is no evidence of the intense preoccupation with body image or physical flaws that is characteristic of body dysmorphic disorder.
Frequency of checking their reflection in a mirror: This is more relevant to body dysmorphic disorder, where the individual is preoccupied with their appearance. There is no evidence in this case that the client is excessively checking their reflection.
Number of items purchased: This is a criterion for hoarding disorder, but there is no evidence in the scenario of the client purchasing or accumulating items uncontrollably.
Ability to present for breakfast on time: This is not a key indicator for monitoring anxiety or OCD. Focusing on the ability to attend a meal does not address the core symptoms of anxiety in this case.

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Correct Answer is A

Explanation

A. Stay with the client for 15 min following meals: Staying with the client for 15 minutes after meals is a common practice to ensure that they do not engage in behaviors like purging or hiding food. It provides supervision and support to prevent the client from engaging in harmful activities.

B. Weigh the client every day for the first week of acute care: Weighing the client daily is not typically recommended, as it may increase anxiety and focus on weight. Weighing may be done periodically, but the frequency should be tailored to the client’s needs and the treatment.

C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.

D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.

A. Secure the client in bed by tightly tucking in sheets. B. Obtain a prescription to renew the restraint prescription every 48 hr. C. Document the interventions used before applying restraints. D. Delegate assistive personnel to check on the client regularly.

Correct Answer is C

Explanation

A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is newly admitted for the treatment of anorexia nervosa. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who is in physical restraints. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

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