A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility one week ago.
A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect, click on the finding again.
The client appears to be well-groomed.
The client’s current weight is 54 kg (119 lb.).
The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare.
The client verbalizes a decreased appetite and gastrointestinal discomfort.
The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
The client verbalizes that bullying experienced during high school has led to anxiety.
The client engages in thought-stopping behavioral therapy and cognitive restructuring.
The client reports taking escitalopram 20 mg daily, 2 hours after breakfast.
The client appears to be well-groomed
The client’s current weight is 54 kg (119 lb.)
The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare
The client verbalizes a decreased appetite and gastrointestinal discomfort
The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
The client verbalizes that bullying experienced during high school has led to anxiety
The client engages in thought-stopping behavioral therapy and cognitive restructuring
The client reports taking escitalopram 20 mg daily, 2 hours after breakfast
The Correct Answer is ["A","C","G","H"]
Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.
An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.
Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.
Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.
The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.
Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.
Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.
Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.
Correct Answer is C
Explanation
Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.
Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.
Choice C reason: Attending to personal hygiene can be a significant issue for clients with borderline personality disorder, as self-care routines may be neglected during periods of intense emotional distress. Including this in the treatment plan focuses on improving daily functioning and self-care abilities.
Choice D reason: Communicating needs is an important skill for all clients, but it is not specific to the treatment of borderline personality disorder. The focus should be on outcomes that address the core symptoms and behaviors of the disorder.
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