A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has an anxiety disorder?

"I check my breasts for lumps every day, but I'm still really scared about getting breast cancer."

"I have had several negative pregnancy tests, but I know they are all wrong."

"I double-check my pills because I think the pharmacist may be putting poison in them."

"I feel really nervous when my partner goes to work, and I am home alone during the day."

Answer and Explanation

The Correct Answer is A

A reason: "I check my breasts for lumps every day, but I'm still really scared about getting breast cancer." This statement reflects excessive worry and fear, which are characteristic of an anxiety disorder. The client's behavior of frequent checking and ongoing fear is consistent with health-related anxiety.

B reason: "I have had several negative pregnancy tests, but I know they are all wrong." This statement suggests a possible delusion, which is more indicative of a psychotic disorder rather than an anxiety disorder.

C reason: "I double-check my pills because I think the pharmacist may be putting poison in them." This statement indicates paranoia, which is more characteristic of a psychotic disorder rather than an anxiety disorder.

D reason: "I feel really nervous when my partner goes to work, and I am home alone during the day." While this statement reflects anxiety, it is less specific to an anxiety disorder and could be associated with general situational stress. The first statement better captures the ongoing, irrational fear typical of anxiety disorders.

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

Explanation

A reason: Hallucinations. Hallucinations can be distressing and are associated with various mental health conditions, but they are not a direct indicator of suicide risk without other contributing factors.

B reason: Depression. Depression is a significant risk factor for suicide. Clients experiencing persistent sadness, hopelessness, and a lack of interest in life are at a higher risk for attempting suicide.

C reason: Delusions. Delusions, particularly those that are paranoid or nihilistic, can contribute to feelings of hopelessness and despair, increasing the risk of suicide attempts.

D reason: Catatonia. Catatonia involves motor immobility and behavioral abnormality. While it is a serious condition requiring treatment, it is not a direct indicator of suicide risk without other contributing factors.

E reason: Tinnitus. Tinnitus, or ringing in the ears, is not associated with an increased risk of suicide. It is a physical symptom that does not directly influence suicidal behavior.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is C

Explanation

A reason: Document the client's behavior once every hour. While documenting the client's behavior is important, it should be done more frequently than once every hour. Monitoring should be continuous to ensure the client's safety.

B reason: Keep the client in restraints until the prescription expires. Restraints should be used for the shortest duration necessary to ensure safety, not just until the prescription expires. Regular assessments are needed to determine if they can be removed earlier.

C reason: Conduct a debriefing regarding the client with the unit staff. Debriefing with the unit staff helps ensure everyone is informed about the client's condition, the reasons for using restraints, and the plan for ongoing care. This promotes a team approach to managing the client's behavior.

D reason: Request an evaluation of the client within 12 hours of application of restraints. An evaluation should be conducted much sooner than 12 hours, typically within an hour of applying restraints, to assess the client's physical and mental status and determine if continued use is justified.

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A nurse on a mental health unit is leading a group therapy session for a group of clients. Which of the following statements should the nurse expect from a client who has an anxiety disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a history of suicide attempts. Which of the following findings places the client at risk for another suicide attempt?

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

Explanation

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Correct Answer is C

Explanation

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