Question 1

The nurse is evaluating the care plan for a client diagnosed with agoraphobia.Which client statement indicates the goals of treatment have been met?

Accepted Answer

A) The client who acknowledges that leaving the home alone is difficult but is committed to keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing healthy ways of responding to the fear. The other statements indicate that the client has not met an appropriate goal in responding to the fear.
B) The client who acknowledges that leaving the home alone is difficult but is committed to keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing healthy ways of responding to the fear. The other statements indicate that the client has not met an appropriate goal in responding to the fear.
C) The client who acknowledges that leaving the home alone is difficult but is committed to keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing healthy ways of responding to the fear. The other statements indicate that the client has not met an appropriate goal in responding to the fear.
D) The client who acknowledges that leaving the home alone is difficult but is committed to keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing healthy ways of responding to the fear. The other statements indicate that the client has not met an appropriate goal in responding to the fear.

Question 2

During the assessment,the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang.Which should the nurse assume regarding the client's behavior?

Accepted Answer

A) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.
B) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.
C) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.
D) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event that are triggered by daily events such as a door banging. The client's reaction to hearing a loud bang from a door could have made the client recall being at home during the home invasion. The client most likely did not think that the assessment was concluded or that there was an earthquake. The client would not have abruptly begun to run out of the room if checking for the source of the loud noise.

Question 3

A client states to the nurse,"I experience shortness of breath and dizziness every time I get into an elevator." Which actions by the nurse are appropriate based on this data? Select all that apply.

Accepted Answer

A) Deep breathing exercises can help the client reduce the anxiety associated with a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the client avoid elevators will not help the client. Asking the client how he has survived in life so far with elevators will not help the situation. Telling the client that elevators are completely safe might not be true and should not be said to the client.
B) Deep breathing exercises can help the client reduce the anxiety associated with a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the client avoid elevators will not help the client. Asking the client how he has survived in life so far with elevators will not help the situation. Telling the client that elevators are completely safe might not be true and should not be said to the client.
C) Deep breathing exercises can help the client reduce the anxiety associated with a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the client avoid elevators will not help the client. Asking the client how he has survived in life so far with elevators will not help the situation. Telling the client that elevators are completely safe might not be true and should not be said to the client.
D) Deep breathing exercises can help the client reduce the anxiety associated with a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the client avoid elevators will not help the client. Asking the client how he has survived in life so far with elevators will not help the situation. Telling the client that elevators are completely safe might not be true and should not be said to the client.
E) Deep breathing exercises can help the client reduce the anxiety associated with a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the client avoid elevators will not help the client. Asking the client how he has survived in life so far with elevators will not help the situation. Telling the client that elevators are completely safe might not be true and should not be said to the client.

Question 4

A client states,"I haven't left my house for 6 years." Based on this data,which diagnosis does the nurse anticipate for this client?

Accepted Answer

A) Agoraphobia is the fear of places or situations where the individual feels unable to escape. Because of these fears, the individual may not leave the home. Social phobia is a fear of social or performance situations where embarrassment may occur. Hematophobia is the fear of blood. Pathophobia is the fear of disease.
B) Agoraphobia is the fear of places or situations where the individual feels unable to escape. Because of these fears, the individual may not leave the home. Social phobia is a fear of social or performance situations where embarrassment may occur. Hematophobia is the fear of blood. Pathophobia is the fear of disease.
C) Agoraphobia is the fear of places or situations where the individual feels unable to escape. Because of these fears, the individual may not leave the home. Social phobia is a fear of social or performance situations where embarrassment may occur. Hematophobia is the fear of blood. Pathophobia is the fear of disease.
D) Agoraphobia is the fear of places or situations where the individual feels unable to escape. Because of these fears, the individual may not leave the home. Social phobia is a fear of social or performance situations where embarrassment may occur. Hematophobia is the fear of blood. Pathophobia is the fear of disease.

Question 5

A client diagnosed with obsessive-compulsive disorder (OCD)is being admitted as an inpatient.The client is obsessed with thoughts of symmetry.Which compulsive behaviors does the nurse anticipate when performing the admission assessment? Select all that apply.

Accepted Answer

A) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate common behaviors of a client whose obsession is symmetry. A client whose obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates repetitive performance of decontamination practices, such as repetitive hand washing; avoidance of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as repeatedly cleaning the top of the bedside table.
B) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate common behaviors of a client whose obsession is symmetry. A client whose obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates repetitive performance of decontamination practices, such as repetitive hand washing; avoidance of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as repeatedly cleaning the top of the bedside table.
C) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate common behaviors of a client whose obsession is symmetry. A client whose obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates repetitive performance of decontamination practices, such as repetitive hand washing; avoidance of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as repeatedly cleaning the top of the bedside table.
D) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate common behaviors of a client whose obsession is symmetry. A client whose obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates repetitive performance of decontamination practices, such as repetitive hand washing; avoidance of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as repeatedly cleaning the top of the bedside table.
E) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate common behaviors of a client whose obsession is symmetry. A client whose obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates repetitive performance of decontamination practices, such as repetitive hand washing; avoidance of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as repeatedly cleaning the top of the bedside table.

Question 6

The nurse suspects a client is experiencing posttraumatic stress disorder when which are noted during the assessment process? Select all that apply.

Accepted Answer

A) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
B) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
C) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
D) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.
E) Risk factors for the development of posttraumatic stress disorder include watching others be harmed or killed, the presence of a preexisting mental illness, and the stress associated with the loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the disorder.

Question 7

A client wants to visit family members who live in Asia but has a fear of flying.Which strategy is an appropriate treatment option for this client?

Accepted Answer

A) Cognitive restructuring is based on the belief than anxiety stems from erroneous interpretations of situations. The client learns to reframe or relabel a frightening situation or activity so that it becomes less threatening. Meditation helps with relaxation. The use of antianxiety medication will not help the client learn how to cope with the anxiety associated with flying. Physical exercise does not directly deal with cognition.
B) Cognitive restructuring is based on the belief than anxiety stems from erroneous interpretations of situations. The client learns to reframe or relabel a frightening situation or activity so that it becomes less threatening. Meditation helps with relaxation. The use of antianxiety medication will not help the client learn how to cope with the anxiety associated with flying. Physical exercise does not directly deal with cognition.
C) Cognitive restructuring is based on the belief than anxiety stems from erroneous interpretations of situations. The client learns to reframe or relabel a frightening situation or activity so that it becomes less threatening. Meditation helps with relaxation. The use of antianxiety medication will not help the client learn how to cope with the anxiety associated with flying. Physical exercise does not directly deal with cognition.
D) Cognitive restructuring is based on the belief than anxiety stems from erroneous interpretations of situations. The client learns to reframe or relabel a frightening situation or activity so that it becomes less threatening. Meditation helps with relaxation. The use of antianxiety medication will not help the client learn how to cope with the anxiety associated with flying. Physical exercise does not directly deal with cognition.

Question 8

The nurse is providing care to several clients at an outpatient clinic.Which client is at the greatest risk for developing a social anxiety disorder?

Accepted Answer

A) A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.
B) A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.
C) A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.
D) A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.
E) A 14-year-old girl would be at highest risk for developing social anxiety disorder because social anxiety disorder (formerly known as social phobia) typically develops between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social anxiety disorder almost never occurs after the age of 25.

Question 9

A client witnessed a violent bank robbery.Which assessment findings would indicate that the client is experiencing posttraumatic stress disorder? Select all that apply.

Accepted Answer

A) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
B) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
C) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
D) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.
E) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not symptoms of posttraumatic stress disorder.

Question 10

The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago.Which should the nurse include in the client's plan of care?

Accepted Answer

A) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
B) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
C) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.
D) The nurse should plan to provide the client with information on the treatments available for posttraumatic stress disorder. Information on exercise and activities of daily living will most likely not help the client's symptoms. Referral to the local employment agency may or may not be necessary.

Question 11

A nurse is providing discharge instructions to a client recently diagnosed with obsessive-compulsive disorder (OCD)and prescribed Fluvoxamine (Luvox).Which statement made by the client indicates to the nurse that the client understands the instructions?

Accepted Answer

A) This statement indicates that the client understands instruction regarding this medication. A client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a physician may begin gradually tapering, while observing the client for symptom exacerbation. Fluvoxamine (Luvox) does have side effects; however, it has fewer side effects than clomipramine and is recommended for the first medication trial. Fluvoxamine (Luvox) is approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD.
B) This statement indicates that the client understands instruction regarding this medication. A client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a physician may begin gradually tapering, while observing the client for symptom exacerbation. Fluvoxamine (Luvox) does have side effects; however, it has fewer side effects than clomipramine and is recommended for the first medication trial. Fluvoxamine (Luvox) is approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD.
C) This statement indicates that the client understands instruction regarding this medication. A client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a physician may begin gradually tapering, while observing the client for symptom exacerbation. Fluvoxamine (Luvox) does have side effects; however, it has fewer side effects than clomipramine and is recommended for the first medication trial. Fluvoxamine (Luvox) is approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD.
D) This statement indicates that the client understands instruction regarding this medication. A client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a physician may begin gradually tapering, while observing the client for symptom exacerbation. Fluvoxamine (Luvox) does have side effects; however, it has fewer side effects than clomipramine and is recommended for the first medication trial. Fluvoxamine (Luvox) is approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD.

Question 12

Which nursing diagnosis would be appropriate for a client with a fear of doctors and hospitals?

Accepted Answer

A) The client with a fear of doctors and hospitals might not participate in routine healthcare activities, which could lead to ineffective health maintenance. There is not enough information to determine whether the client is or is not experiencing ineffective coping, anxiety, or depression.
B) The client with a fear of doctors and hospitals might not participate in routine healthcare activities, which could lead to ineffective health maintenance. There is not enough information to determine whether the client is or is not experiencing ineffective coping, anxiety, or depression.
C) The client with a fear of doctors and hospitals might not participate in routine healthcare activities, which could lead to ineffective health maintenance. There is not enough information to determine whether the client is or is not experiencing ineffective coping, anxiety, or depression.
D) The client with a fear of doctors and hospitals might not participate in routine healthcare activities, which could lead to ineffective health maintenance. There is not enough information to determine whether the client is or is not experiencing ineffective coping, anxiety, or depression.

Question 13

A client tells the nurse about continually reliving a situation of being robbed and shot by a gunman.Which nursing diagnosis is most appropriate for this client?

Accepted Answer

A) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
B) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
C) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
D) The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.

Question 14

A client asks for a hospital bed near the door because of a fear of being trapped in a room and not being able to get out.When planning care for this client,which does the nurse include as a possible cause for this client's fear?

Accepted Answer

A) Factors that predispose an individual to develop phobias, such as the fear of not getting out of a room, include traumatic events. Genetic predisposition would mean that others in the client's family have the same fear. Informational transmission means the fear would be explained or demonstrated through the media. Observing others would mean that the client has seen others demonstrate the same fear of not being near the door.
B) Factors that predispose an individual to develop phobias, such as the fear of not getting out of a room, include traumatic events. Genetic predisposition would mean that others in the client's family have the same fear. Informational transmission means the fear would be explained or demonstrated through the media. Observing others would mean that the client has seen others demonstrate the same fear of not being near the door.
C) Factors that predispose an individual to develop phobias, such as the fear of not getting out of a room, include traumatic events. Genetic predisposition would mean that others in the client's family have the same fear. Informational transmission means the fear would be explained or demonstrated through the media. Observing others would mean that the client has seen others demonstrate the same fear of not being near the door.
D) Factors that predispose an individual to develop phobias, such as the fear of not getting out of a room, include traumatic events. Genetic predisposition would mean that others in the client's family have the same fear. Informational transmission means the fear would be explained or demonstrated through the media. Observing others would mean that the client has seen others demonstrate the same fear of not being near the door.

Question 15

A nurse educator is teaching a group of new staff members recently hired on a behavioral health unit.Which examples of cognitive-behavioral therapy (CBT)does the educator include as expected when providing care to clients on the unit? Select all that apply.

Accepted Answer

A) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.
B) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.
C) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.
D) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.
E) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a pharmacological therapy that may be beneficial if used with CBT.

Question 16

The nurse is providing teaching to a client diagnosed with a social phobia.Which client statement indicates appropriate understanding of the information presented?

Accepted Answer

A) People with social phobias may medicate themselves with alcohol or drugs to make it possible to endure social situations. This is not evidence that teaching has been effective. The individual with a social phobia may also avoid all situations in which the phobia occurs. This is also not evidence of successful instruction. Learning to control anxiety by deep breathing and relaxation is evidence that instruction about social phobias has been successful.
B) People with social phobias may medicate themselves with alcohol or drugs to make it possible to endure social situations. This is not evidence that teaching has been effective. The individual with a social phobia may also avoid all situations in which the phobia occurs. This is also not evidence of successful instruction. Learning to control anxiety by deep breathing and relaxation is evidence that instruction about social phobias has been successful.
C) People with social phobias may medicate themselves with alcohol or drugs to make it possible to endure social situations. This is not evidence that teaching has been effective. The individual with a social phobia may also avoid all situations in which the phobia occurs. This is also not evidence of successful instruction. Learning to control anxiety by deep breathing and relaxation is evidence that instruction about social phobias has been successful.
D) People with social phobias may medicate themselves with alcohol or drugs to make it possible to endure social situations. This is not evidence that teaching has been effective. The individual with a social phobia may also avoid all situations in which the phobia occurs. This is also not evidence of successful instruction. Learning to control anxiety by deep breathing and relaxation is evidence that instruction about social phobias has been successful.

Question 17

A nurse is evaluating the plan of care for a client diagnosed with obsessive-compulsive disorder (OCD).Which client statement indicates a positive outcome for the plan of care?

Accepted Answer

A) The client who acknowledges improvement when washing hands less frequently recognizes that continued obsessive-compulsive behaviors are not an indication of treatment failure and that reductions in behavior signify positive progress. The client who has substituted the ritualistic use of hand sanitizer for the ritualistic hand washing has not demonstrated adequate coping skills to control anxiety related to absence of ritualistic compulsive behaviors. The client who sees nothing wrong with washing hands several times a day does not recognize that the ritualistic hand washing is a problem.
B) The client who acknowledges improvement when washing hands less frequently recognizes that continued obsessive-compulsive behaviors are not an indication of treatment failure and that reductions in behavior signify positive progress. The client who has substituted the ritualistic use of hand sanitizer for the ritualistic hand washing has not demonstrated adequate coping skills to control anxiety related to absence of ritualistic compulsive behaviors. The client who sees nothing wrong with washing hands several times a day does not recognize that the ritualistic hand washing is a problem.
C) The client who acknowledges improvement when washing hands less frequently recognizes that continued obsessive-compulsive behaviors are not an indication of treatment failure and that reductions in behavior signify positive progress. The client who has substituted the ritualistic use of hand sanitizer for the ritualistic hand washing has not demonstrated adequate coping skills to control anxiety related to absence of ritualistic compulsive behaviors. The client who sees nothing wrong with washing hands several times a day does not recognize that the ritualistic hand washing is a problem.
D) The client who acknowledges improvement when washing hands less frequently recognizes that continued obsessive-compulsive behaviors are not an indication of treatment failure and that reductions in behavior signify positive progress. The client who has substituted the ritualistic use of hand sanitizer for the ritualistic hand washing has not demonstrated adequate coping skills to control anxiety related to absence of ritualistic compulsive behaviors. The client who sees nothing wrong with washing hands several times a day does not recognize that the ritualistic hand washing is a problem.

Question 18

Which is the role of the nurse when providing care to a client diagnosed with a phobia?

Accepted Answer

A) The role of the professional nurse caring for clients with phobic disorders is to provide comfort to the client and family and alleviate emotional distress. The nurse supports adaptive coping while empowering the client by providing information, accessing resources, and communicating therapeutically. The nurse should not encourage the client to confront fears or tell the client that the hospital is a safe place. The client may or may not be prescribed medication for the disorder.
B) The role of the professional nurse caring for clients with phobic disorders is to provide comfort to the client and family and alleviate emotional distress. The nurse supports adaptive coping while empowering the client by providing information, accessing resources, and communicating therapeutically. The nurse should not encourage the client to confront fears or tell the client that the hospital is a safe place. The client may or may not be prescribed medication for the disorder.
C) The role of the professional nurse caring for clients with phobic disorders is to provide comfort to the client and family and alleviate emotional distress. The nurse supports adaptive coping while empowering the client by providing information, accessing resources, and communicating therapeutically. The nurse should not encourage the client to confront fears or tell the client that the hospital is a safe place. The client may or may not be prescribed medication for the disorder.
D) The role of the professional nurse caring for clients with phobic disorders is to provide comfort to the client and family and alleviate emotional distress. The nurse supports adaptive coping while empowering the client by providing information, accessing resources, and communicating therapeutically. The nurse should not encourage the client to confront fears or tell the client that the hospital is a safe place. The client may or may not be prescribed medication for the disorder.

Question 19

A client is experiencing severe anxiety associated with a phobia.Which nursing actions are appropriate when providing care to the client? Select all that apply.

Accepted Answer

A) As a client's anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.
B) As a client's anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.
C) As a client's anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.
D) As a client's anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.
E) As a client's anxiety level associated with a phobia increases, judgment and the ability to listen, remember, and learn are impaired. This is not the time to teach or present new information. The nurse should not argue with the client about the perception of reality. The nurse needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be applicable after the client is stabilized.

Question 20

The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder.Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply.

Accepted Answer

A) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.
B) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.
C) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.
D) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.
E) Evidence of effective intervention for posttraumatic stress disorder would be the client being able to sleep throughout the night and verbalizing future plans with family and friends. The client who is unable to enter a car with fewer than three people, keeps all of the lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been successful.

Quiz 31: Stress and Coping