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A nurse is collecting data on a client following cognitive behavioral therapy. Which of the following findings indicates a therapeutic response?

The client is not able to tolerate activity

The clients is restless

The client reports decreased anxiety

The client has an increased heart rate.

Answer and Explanation

The Correct Answer is C

A. The client is not able to tolerate activity

This indicates ongoing physical or psychological distress, not improvement.

B. The client is restless

Restlessness can be a sign of anxiety, agitation, or discomfort, not a therapeutic outcome.

C. The client reports decreased anxiety

A primary goal of cognitive behavioral therapy (CBT) is to help clients manage and reduce anxiety through cognitive restructuring and behavior modification.

D. The client has an increased heart rate

An increased heart rate can signal stress or anxiety, which would not indicate therapeutic progress.

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Correct Answer is A

Explanation

A. Asking the client to rate the pain and assess the site for decreased swelling:

This combines both subjective (pain rating) and objective (swelling) indicators of whether the treatment is working.

B. Having the client perform range-of-motion exercises of the arm:

This does not directly assess the effectiveness of cold therapy and may aggravate a fresh injury.

C. Inspecting the site for increased swelling:

This may indicate ineffective treatment, not effectiveness.

D. Monitoring the client’s pulse rate:

Pulse rate is not a reliable measure for evaluating local pain or swelling.

A. Peripheral edema B. Capillary refill that returns immediately C. Hypertension D. Oliguria

Correct Answer is D

Explanation

A. Peripheral edema:

Edema is a sign of fluid overload, not fluid loss or hypovolemia.

B. Capillary refill that returns immediately:

In hypovolemia, capillary refill is typically delayed (>2 seconds) due to poor perfusion.

C. Hypertension:

Hypovolemia often causes hypotension due to reduced circulating volume.

D. Oliguria:

Decreased urine output (<30 mL/hr) is a classic sign of hypovolemia, as the kidneys reduce output to conserve fluid.

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A nurse is collecting data on a client following cognitive behavioral therapy. Which of the following findings indicates a therapeutic response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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