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 D
Explanation
Choice A reason: Initiating hospice care services is generally considered when the client is in the final stages of Alzheimer's disease and has a life expectancy of 6 months or less. Hospice care focuses on comfort and quality of life, rather than curative treatments. It's an option when the disease has significantly progressed, not typically at the time of initial diagnosis.
Choice B reason: Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain and is being studied as a potential treatment for improving cognitive status in Alzheimer's patients. However, it is not yet a standard treatment and is considered experimental.
Choice C reason: Barbiturate medications are not typically used to control anxiety in Alzheimer's patients due to the risk of dependency and the potential to worsen cognitive impairment. Other medications, such as selective serotonin reuptake inhibitors (SSRIs), are generally preferred for managing anxiety in these patients⁷.
Choice D reason: NMDA receptor antagonists, such as memantine, are medications that can help delay cognitive symptoms in patients with moderate to severe Alzheimer's disease. They work by regulating the activity of glutamate, a neurotransmitter involved in learning and memory, which may be overactive in Alzheimer's disease.
Correct Answer is B
Explanation
Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.
Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.
Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.
Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.
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