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A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?
- A. Ineffective coping
- B. Disturbed thought processes
- C. Chronic low self-esteem
- D. Social isolation
Correct Answer: A
Rationale: The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses an inability to stop worrying about everything is 'Ineffective coping.' This diagnosis indicates the client's struggle to manage anxiety and worry effectively, which aligns with the client's statement. 'Disturbed thought processes' (Choice B) would involve disorganized or irrational thinking patterns, which are not directly related to the client's statement about excessive worry. 'Chronic low self-esteem' (Choice C) refers to a long-standing negative self-evaluation and is not the most fitting diagnosis for the client's current concern. 'Social isolation' (Choice D) pertains to a lack of social interactions and support, which is not the primary issue highlighted by the client's statement.
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A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?
- A. Tell me more about these voices.
- B. Let's explore these voices together.
- C. How long have you been hearing these voices?
- D. Have you told anyone else about these voices?
Correct Answer: A
Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.
A healthcare provider is evaluating a client who is taking selective serotonin reuptake inhibitors (SSRIs) for depression. Which symptom should the healthcare provider identify as an adverse effect that requires immediate attention?
- A. Increased appetite
- B. Weight gain
- C. Blurred vision
- D. Suicidal thoughts
Correct Answer: D
Rationale: Suicidal thoughts are a serious adverse effect associated with SSRIs and require immediate attention. This symptom is critical as it can increase the risk of self-harm or suicide in individuals taking these medications. Increased appetite and weight gain are common side effects of SSRIs but do not require immediate attention. Blurred vision is not a typical adverse effect of SSRIs, making it an incorrect choice. Healthcare providers must promptly recognize and address suicidal thoughts to ensure the safety and well-being of the client.
A client prescribed lithium for bipolar disorder is receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating aged cheeses and processed meats.
- B. I need to maintain a consistent sodium intake.
- C. I should drink plenty of fluids to stay hydrated.
- D. I can take over-the-counter medications without consulting my healthcare provider.
Correct Answer: D
Rationale: The correct answer is D. Taking over-the-counter medications without consulting the healthcare provider is not recommended for clients on lithium therapy as there can be potential interactions between lithium and certain medications. It is crucial for clients on lithium to always consult their healthcare provider before taking any over-the-counter medications to ensure the safety and effectiveness of their treatment. Choices A, B, and C are all correct statements that align with managing lithium therapy, emphasizing the importance of dietary restrictions and adequate hydration, as well as monitoring sodium intake to maintain the therapeutic effects of lithium.
When caring for a client experiencing alcohol withdrawal, which intervention should the nurse implement to prevent complications?
- A. Provide a well-lit environment.
- B. Administer antipsychotic medication as prescribed.
- C. Monitor the client's vital signs closely.
- D. Encourage the client to express their feelings.
Correct Answer: D
Rationale: Encouraging the client to express their feelings is essential during alcohol withdrawal as it can help them cope with the emotional and psychological stress associated with the process. This intervention promotes open communication, allows the client to verbalize their emotions, and may prevent escalating anxiety or agitation, ultimately reducing the risk of complications. Providing a well-lit environment (Choice A) is not directly related to preventing complications of alcohol withdrawal. Administering antipsychotic medication (Choice B) is not the standard treatment for alcohol withdrawal; medications such as benzodiazepines are more commonly used. While monitoring vital signs (Choice C) is important, encouraging the client to express their feelings (Choice D) directly addresses emotional well-being, which is crucial during this vulnerable time.
A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?
- A. Tremors
- B. Nausea and vomiting
- C. Increased blood pressure
- D. Insomnia
Correct Answer: C
Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.