A nurse is caring for a client with a history of left-sided heart failure who begins to experience dyspnea and reports that “it feels hard to catch my breath.” The nurse notes increased respiratory effort and auscultates crackles in the bilateral lung bases. Which initial nursing intervention is most appropriate?

Reinforce teaching of using the incentive spirometer hourly

Encourage the client to cough and deep breathe

Elevate the head of the bed 45 degrees

Place the client in high Fowler’s position

Answer and Explanation

The Correct Answer is D

Choice A reason: Incentive spirometry improves lung expansion but is not the priority in acute heart failure with pulmonary edema. Crackles and dyspnea indicate fluid overload, requiring immediate positioning to reduce respiratory distress, making this intervention less urgent than optimizing breathing mechanics.

Choice B reason: Coughing and deep breathing may help clear airways but do not address the underlying pulmonary edema in left-sided heart failure. Fluid in the alveoli causes crackles and dyspnea, requiring positioning to reduce venous return and improve oxygenation, making this less effective initially.

Choice C reason: Elevating the head of the bed to 45 degrees can reduce venous return and ease breathing in heart failure. However, high Fowler’s position (60–90 degrees) is more effective for severe dyspnea and pulmonary edema, as it maximizes lung expansion and oxygenation.

Choice D reason: High Fowler’s position (60–90 degrees) reduces venous return to the heart, decreasing pulmonary congestion in left-sided heart failure. This alleviates dyspnea and crackles by improving lung expansion and oxygenation, making it the most effective initial intervention for acute respiratory distress in this condition.

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Correct Answer is B

Explanation

Choice A reason: Brief, intense depressive episodes with full recovery are characteristic of major depressive disorder, not dysthymia. Dysthymic disorder involves persistent, less severe symptoms over at least two years, without complete remission, making this an incorrect description.

Choice B reason: Dysthymic disorder is defined by a chronic low mood lasting at least two years, with milder symptoms (e.g., low energy, poor self-esteem) than major depressive disorder. This persistent, less severe state aligns with the diagnosis, making this the correct feature.

Choice C reason: Depressive symptoms for two weeks during winter months describe seasonal affective disorder, not dysthymia. Dysthymic disorder is chronic and not seasonally limited, with symptoms persisting for years, making this an incorrect characteristic.

Choice D reason: Sudden, intense depressive episodes followed by high-energy periods suggest bipolar disorder, not dysthymia. Dysthymic disorder involves continuous low-grade depression without manic or hypomanic episodes, making this an inaccurate description of the condition.

A. Encourage the client to talk about the purpose of the rituals B. Distract the client from rituals with other activities C. Ask the client to stop performing the rituals D. Allow the client to perform their rituals

Correct Answer is D

Explanation

Choice A reason: Encouraging discussion about the purpose of rituals may help the client gain insight into their OCD but can increase anxiety if they feel pressured to explain compulsive behaviors. This approach is less effective for immediate security compared to allowing rituals, which reduces distress.

Choice B reason: Distracting the client from rituals with activities may disrupt their compulsive behaviors, increasing anxiety and reducing their sense of control. This can exacerbate OCD symptoms, as rituals are a coping mechanism, making this approach less effective for promoting immediate security.

Choice C reason: Asking the client to stop performing rituals can significantly increase anxiety, as these behaviors are driven by intrusive thoughts and provide temporary relief. Forcing cessation without therapeutic support can destabilize the client, reducing their sense of security and worsening OCD symptoms.

Choice D reason: Allowing the client to perform rituals reduces immediate anxiety by permitting their coping mechanism, which is central to OCD. This fosters a sense of security, as the client feels understood and less threatened, creating a stable environment for building trust and initiating therapy.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with dysthymic disorder (persistent depressive disorder). Which of the following is a characteristic feature of dysthymic disorder?

Correct Answer is B

Explanation

The nurse is caring for a client with obsessive-compulsive disorder (OCD). Which action by the nurse will increase the client’s sense of security?

Correct Answer is D

Explanation

The nurse observes a client who is rapidly pacing, wringing their hands, and trembling. Their speech is high-pitched, they are unable to concentrate, and have restricted problem-solving. The nurse identifies the client’s anxiety level as:

The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise?

A nurse is preparing to administer metoprolol 25 mg PO to a client with a history of hypertension and heart failure. The client’s vital signs are: BP 132/78 mm Hg, HR 86 beats per minute, and respiratory rate 18 breaths per minute. Which action should the nurse take?

The nurse is evaluating the progress of a client with bulimia. Which behavior would indicate that the client is making positive progress?

Which of the four classes of medications used for Generalized Anxiety Disorder (GAD) is considered the safest because of low incidence of side effects and lack of physiological dependence?

A nurse is visiting a client in the home setting after discharge from the hospital for treatment of multiple area skin infections and cellulitis. Which behavior does the nurse document as a dangerous sign that the client is hoarding?

A client prescribed lithium carbonate 300 mg twice daily three months ago comes to the emergency department with mental confusion, ataxia, excessive diluted urine (polyuria), and blurred vision. Which lithium level would the nurse expect?