Exhibits

The nurse reviews the clinical findings.

For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.

Avoidance

Suicidal ideation

Nightmares

Feelings of guilt

Lack of interest

Sleep disturbance

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B,C"},"E":{"answers":"B"},"F":{"answers":"A,B,C"}}

Rationale:

Avoidance: Avoidance of reminders of the trauma, including people, places, or conversations related to the event, is a core diagnostic criterion for PTSD. The client avoids visiting fellow platoon members, suggesting avoidance behavior linked to her combat trauma.
Suicidal ideation: Thoughts of death or suicide are hallmark symptoms of MDD. The client was found writing a suicide note and planning to shoot herself, which strongly supports the diagnosis of MDD.
Nightmares: Recurrent distressing dreams or nightmares related to the traumatic event are common in PTSD. The client reports frequent nightmares linked to her war experience.
Feelings of guilt: Excessive guilt is common in MDD, often irrational and self-deprecating. In PTSD, survivors’ guilt is prevalent, especially when others died in the traumatic event, as expressed by the client lamenting that her life was spared over her comrades'.
Lack of interest: Markedly diminished interest or pleasure in previously enjoyed activities is a core symptom of MDD. The client’s withdrawal from social connections reflects this loss of interest.
Sleep disturbance: Insomnia is prevalent in GAD due to excessive worry, in MDD due to mood dysregulation, and in PTSD due to nightmares and hyperarousal. The client’s reported insomnia applies to all three conditions.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for Correct Choices:

Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs.
Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early.

Rationale for Incorrect Choices:

Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status.
Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics.
Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration.
Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.

A. Encouraging the client to join a support group. B. Allowing the client to ventilate feelings. C. Shaking the client's hand during an introduction. D. Wearing gloves when interviewing the client.

Correct Answer is C

Explanation

Rationale:
A. Encouraging the client to join a support group: While beneficial, referring the client to a support group does not immediately address the client's psychosocial need for acceptance in the nurse-client interaction. Acceptance should first be modeled directly by caregivers.

B. Allowing the client to ventilate feelings: This addresses emotional support but does not necessarily promote acceptance. The client may still feel socially isolated or judged if the nurse maintains physical distance or acts hesitantly.

C. Shaking the client's hand during an introduction: This action demonstrates respect, inclusion, and nonjudgmental care. It helps normalize the interaction and signals to the client that the nurse does not view their skin condition as repulsive or infectious. Such gestures reduce stigma and build trust.

D. Wearing gloves when interviewing the client: Gloving when unnecessary can send a message that the client is contaminated. For non-contact interviews, gloves are not required and may make the client feel rejected or judged. It contradicts acceptance goals.

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Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

Exhibits The nurse reviews the clinical findings. For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Correct Answer is C

Explanation

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?

The camp nurse is teaching adolescents about the prevention of tinea pedis. Which instruction should the nurse include in the teaching plan?

Patient Data Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

Exhibits

The nurse reviews the clinical findings.

For each of the findings listed, click to indicate which are consistent with the disease process of major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder. Each column must have at least one response selected.