Question 1

Which assessment findings indicate to the nurse that a client is experiencing stress? Select all that apply.

Accepted Answer

A) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.
B) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.
C) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.
D) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.
E) The client is experiencing both behavioral (nail chewing) and physical (foot tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are not indications of stress.

Question 2

A client is recently prescribed risperidone (Risperdal)by the healthcare provider.Which would be a priority nursing consideration for this client?

Accepted Answer

A) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.
B) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.
C) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.
D) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing blood pressure and heart rate would be a priority nursing consideration for the client taking Inderal.

Question 3

Which intervention would help a client who is demonstrating stress about being hospitalized and concerned about the needs of the children at home?

Accepted Answer

A) The best way that the nurse can help the client who is stressed with a new illness and family responsibilities is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent's home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.
B) The best way that the nurse can help the client who is stressed with a new illness and family responsibilities is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent's home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.
C) The best way that the nurse can help the client who is stressed with a new illness and family responsibilities is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent's home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.
D) The best way that the nurse can help the client who is stressed with a new illness and family responsibilities is to ask if there is anyone who can help the client at home. Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Sending the children to a grandparent's home might not work if the children are in school and the grandparent lives far away. Asking the client if there is anything that is needed once discharged is not enough. The nurse needs to do something else.

Question 4

The nurse suspects that a healthy client could be experiencing stress because of which laboratory result?

Accepted Answer

A) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and more accurate. However, they may be necessary to rule out medical conditions that can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing stress because of an increase in adrenal function. One physiological indicator of stress is an increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The other laboratory values are within normal limits.
B) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and more accurate. However, they may be necessary to rule out medical conditions that can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing stress because of an increase in adrenal function. One physiological indicator of stress is an increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The other laboratory values are within normal limits.
C) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and more accurate. However, they may be necessary to rule out medical conditions that can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing stress because of an increase in adrenal function. One physiological indicator of stress is an increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The other laboratory values are within normal limits.
D) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and more accurate. However, they may be necessary to rule out medical conditions that can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing stress because of an increase in adrenal function. One physiological indicator of stress is an increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The other laboratory values are within normal limits.

Question 5

The nurse is instructing a client with an anxiety disorder on behavioral tools to help with coping.Which tools to help with coping should the nurse include in the teaching session? Select all that apply.

Accepted Answer

A) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.
B) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.
C) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.
D) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.
E) Behavioral tools to help with coping include reading self-help literature, practicing relaxation techniques such as yoga, and journaling stressors and emotional responses and alternatives. Thought stopping and distraction are cognitive coping tools.

Question 6

Which is the priority nursing action when providing care to a client who demonstrate signs of escalating anxiety?

Accepted Answer

A) The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.
B) The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.
C) The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.
D) The nurse should first isolate the severely anxious or panicked client in a safe, quiet, protective environment. The nurse should not leave the client unattended. Phoning the physician may not be helpful to the client. Medications can be provided once the client is in a safe, protective environment.

Question 7

A nurse on the behavioral health unit is caring for a client diagnosed with depression,who just lost a spouse in a motor-vehicle accident.The client states to the nurse,"my wife would not have wanted to live if she were disabled." Based on this statement,which defense mechanism is the client using?

Accepted Answer

A) Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.
B) Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.
C) Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.
D) Intellectualization is a mechanism by which an emotional response that normally would accompany an uncomfortable or painful incident is evaded by the use of rational explanations that remove from the incident any personal significance and feelings. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the transferring or discharging of emotional reactions from one object or individual to another object or individual.

Question 8

The nurse is evaluating medication teaching for a client who recently started taking fluoxetine (Prozac)for anxiety.Which statement by the client indicates appropriate understanding of the information presented?

Accepted Answer

A) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12 weeks to see a full response to the drug.
B) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12 weeks to see a full response to the drug.
C) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12 weeks to see a full response to the drug.
D) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12 weeks to see a full response to the drug.

Question 9

A client states to the nurse that learning how to use the blood glucose machine will have to wait until holiday events are planned.Which cognitive indication of stress is the client demonstrating?

Accepted Answer

A) The client is demonstrating suppression, which is the conscious and willful act of putting a thought or feeling out of mind. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or manipulation of a situation so that threatening events do not occur. Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge.
B) The client is demonstrating suppression, which is the conscious and willful act of putting a thought or feeling out of mind. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or manipulation of a situation so that threatening events do not occur. Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge.
C) The client is demonstrating suppression, which is the conscious and willful act of putting a thought or feeling out of mind. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or manipulation of a situation so that threatening events do not occur. Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge.
D) The client is demonstrating suppression, which is the conscious and willful act of putting a thought or feeling out of mind. The client is focusing on other needs and not the need to learn how to use the blood glucose machine. Problem solving involves thinking through the threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or manipulation of a situation so that threatening events do not occur. Self-control is assuming a manner and facial expression that convey a sense of being in control or in charge.

Question 10

A client,who was recently being laid off from work,is scheduled for a biopsy to detect a malignancy.When planning this client's care,which does the nurse include?

Accepted Answer

A) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client's financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.
B) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client's financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.
C) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client's financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.
D) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with a change in employment. The nurse should plan interventions to address anxiety. Social services may or may not be needed for the client's financial planning. Delaying the biopsy will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.

Question 11

Which instruction by the nurse to a client prescribed diazepam (Valium)for anxiety and stress is appropriate?

Accepted Answer

A) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client's anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.
B) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client's anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.
C) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client's anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.
D) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a client's anxiety but is generally not recommended for use beyond a few weeks because of its addictive properties. The nurse should instruct the client that the medication is good to use for the short term only. There is no indication that this medication needs to be taken with a meal. Instructing the client to take the medication every time feelings of stress become overwhelming could lead to an overdose and should not be done.

Question 12

A client complains about the stress of having to work long hours and missing daily exercise routines.Which response by the nurse is appropriate?

Accepted Answer

A) The client had been exercising but has not because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client's not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest using alcohol to deal with stress.
B) The client had been exercising but has not because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client's not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest using alcohol to deal with stress.
C) The client had been exercising but has not because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client's not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest using alcohol to deal with stress.
D) The client had been exercising but has not because of additional work, which is causing stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the stress on the body. The nurse should not reinforce the client's not exercising. Meditation might be beneficial, but because the client mentioned initially exercising and not meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest using alcohol to deal with stress.

Question 13

While caring for a critically ill child,the child's mother becomes distraught and begins to cry loudly while stroking the child's face.Which is the best response by the nurse?

Accepted Answer

A) In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.
B) In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.
C) In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.
D) In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. Although the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information.

Question 14

A client,who is experiencing slight anxiety,is trembling and communicating in a manner that makes it difficult for the nurse to understand the client's needs.Based on this data,which level of anxiety is the client likely experiencing?

Accepted Answer

A) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand and trembling can occur. Communication may not be understandable at all when the client reaches the panic stage.
B) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand and trembling can occur. Communication may not be understandable at all when the client reaches the panic stage.
C) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand and trembling can occur. Communication may not be understandable at all when the client reaches the panic stage.
D) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand and trembling can occur. Communication may not be understandable at all when the client reaches the panic stage.

Question 15

The nurse is assessing a client who demonstrates physiologic manifestations of a stress response.Which physiologic manifestations result for the inhibition of the parasympathetic nervous system? Select all that apply.

Accepted Answer

A) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.
B) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.
C) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.
D) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.
E) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all due to sympathetic nervous system stimulation.

Question 16

Which nursing intervention minimizes the stress and anxiety of hospitalization for a client?

Accepted Answer

A) The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.
B) The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.
C) The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.
D) The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.

Question 17

The nurse is admitting a client with panic anxiety to the behavioral health unit.Which clinical manifestations would indicate that the client's anxiety is at a panic level of severity? Select all that apply.

Accepted Answer

A) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.
B) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.
C) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.
D) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.
E) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate level of severity.

Question 18

A nurse on the behavioral health unit is leading a group regarding risk factors for anxiety.At the completion of group work,which comment made by a client would indicate the need for further teaching?

Accepted Answer

A) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.
B) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.
C) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.
D) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor. For some clients multiple stressors, such as chronic illness with loss of employment, are risk factors. So this statement indicates a need for further teaching. The other statements are accurate and therefore do not require further teaching.

Question 19

After a mammogram,a client is told that she needs a fine needle aspirate of a breast mass.Which actions by the client demonstrates engagement in a primary appraisal of the stressful situation?

Accepted Answer

A) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.
B) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.
C) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.
D) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary appraisal. The client holding her breath while the nurse is talking is evaluating coping resources and options. This is a secondary appraisal. The client who sits in the dressing room and cries is applying a coping resource. This is coping. The client who schedules the procedure at the earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the situation based on new information.

Question 20

While attempting to choose a nursing diagnosis,the nurse must decide whether a client is experiencing anxiety or fear.Which key point would allow the nurse to plan care based on the nursing diagnosis of Anxiety?

Accepted Answer

A) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a milder form of fear.
B) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a milder form of fear.
C) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a milder form of fear.
D) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a milder form of fear.

Quiz 31: Stress and Coping