A nurse is creating a plan of care for a client who has generalized anxiety disorder and was recently admitted following a stressful life event. Which of the following interventions should the nurse include in the plan?

Provide detailed directions for the client's expected behavioral changes.

Request the client write down an evaluation of personal strengths.

List alternative interpretations of the client's illogical thinking.

Encourage the client to participate in group recreational activities to help concentration.

Answer and Explanation

The Correct Answer is B

A) Provide detailed directions for the client's expected behavioral changes
Giving detailed directions may overwhelm the client, increasing anxiety. It's more effective to offer support and simple, clear guidance to reduce stress.

B) Request the client write down an evaluation of personal strengths
Encouraging the client to focus on personal strengths can boost self-esteem and resilience, helping them cope with anxiety by promoting a positive self-image and reinforcing their ability to manage stress.

C) List alternative interpretations of the client's illogical thinking
While reframing thoughts can be helpful, this approach might be too confrontational initially. It's important to build trust and allow the client to explore thoughts at their own pace.

D) Encourage the client to participate in group recreational activities to help concentration
While recreational activities can be beneficial, they may not directly address anxiety management. Individual reflection on strengths can be a more immediate way to enhance coping skills.

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Correct Answer is D

Explanation

A) Drink 8 oz of milk when hypoglycemia develops:
While consuming a fast-acting carbohydrate is important during hypoglycemia, 8 oz of milk may not be the most effective choice. Typically, glucose tablets or juice are recommended as they provide a quicker absorption of sugar into the bloodstream.

B) Initiate a 1,400-calorie diet daily:
Caloric needs should be individualized based on the adolescent’s age, weight, activity level, and overall health. A fixed 1,400-calorie diet might not be appropriate for every adolescent and could lead to insufficient energy intake or excessive restriction.

C) Rotate the insulin injection site to a different area of the body with every other injection:
While rotating injection sites is important to prevent lipodystrophy, it is generally recommended to use different sites within the same area (such as different spots on the abdomen) rather than entirely different areas of the body with each injection. This ensures consistent absorption of insulin.

D) Keep unopened insulin refrigerated at 4.44° C (40° F):
Unopened insulin should be stored in the refrigerator to maintain its potency until it is ready to be used. This temperature range ensures the insulin remains stable and effective for use.

A. Position the cast on a plastic-covered pillow. B. Perform neurovascular checks every 2 hr. C. Instruct the client to avoid moving the fingers on the left hand. D. Touch the cast with the palms of the hands when moving the client.

Correct Answer is B

Explanation

A) Position the cast on a plastic-covered pillow:
Positioning the cast on a plastic-covered pillow is not recommended because the plastic can trap moisture and heat, potentially affecting the cast's integrity as it dries. Instead, a soft, absorbent material should be used to support the cast.

B) Perform neurovascular checks every 2 hr:
Frequent neurovascular checks are essential to monitor for complications such as compartment syndrome, nerve damage, or impaired circulation. This action helps ensure that any changes in sensation, movement, or circulation are identified and addressed promptly.

C) Instruct the client to avoid moving the fingers on the left hand:
Encouraging the client to move their fingers is important to prevent stiffness and swelling and to promote circulation. Instructing the client to avoid moving their fingers is not appropriate and could lead to complications.

D) Touch the cast with the palms of the hands when moving the client:
Handling a wet plaster cast with the palms of the hands is correct to prevent indentations and pressure points that could cause skin irritation or pressure sores. However, this action is not as critical as performing frequent neurovascular checks to ensure the client's safety and monitor for complications.

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A nurse is creating a plan of care for a client who has generalized anxiety disorder and was recently admitted following a stressful life event. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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