A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

"Come with me to an area where we can talk without interruption."

"Providers usually recommend relaxation exercises for clients who are as upset as you are."

"An antianxiety pill works best for situations like this."

"Most clients with anxiety issues benefit from lying down.".

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Come with me to an area where we can talk without interruption."

Choice A rationale:

The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.

Choice B rationale:

This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.

Choice C rationale:

Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.

Choice D rationale:

Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.

Choice B rationale:

Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.

Choice C rationale:

Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.

Choice E rationale:

Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.

Choice D rationale:

Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.

A. Sudden unexplained loss of peripheral sensation. B. Obsession over a fictitious defect in physical appearance. C. Prior physical health followed by the need for two surgeries within the last three months. D. Continuous worry about the undiagnosed presence of an illness.

Correct Answer is D

Explanation

The correct answer is choice D: Continuous worry about the undiagnosed presence of an illness.

Choice A rationale:

Sudden unexplained loss of peripheral sensation is not typically associated with illness anxiety disorder. This symptom may be indicative of a neurological condition and would require further medical evaluation to determine the cause.

Choice B rationale:

Obsession over a fictitious defect in physical appearance is more characteristic of body dysmorphic disorder, not illness anxiety disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance, which are not observable or appear slight to others.

Choice C rationale:

Having prior physical health followed by the need for two surgeries within the last three months does not necessarily indicate illness anxiety disorder. This choice does not provide enough context to link it to illness anxiety disorder, as it could be related to many other health conditions.

Choice D rationale:

Continuous worry about the undiagnosed presence of an illness is a key finding in illness anxiety disorder. Individuals with this disorder are excessively concerned with and preoccupied by the belief that they have, or are in danger of developing, a serious undiagnosed illness despite medical reassurance.

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A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

Correct Answer is ["A","B","C","E"]

Explanation

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

Correct Answer is D

Explanation

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

A nurse educator is discussing community mental health with a group of nursing students. Based on the public health model, which of the following statements made by one of the students indicates correct information about primary prevention?

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?