Nokea
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.
You may also like to solve these questions
A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Instruct the client to listen to music to drown out the voices.
- C. Tell the client that the voices are not real.
- D. Distract the client from the voices.
Correct Answer: A
Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia.
Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.
A client with depression is experiencing anhedonia. Which statement by the client reflects this symptom?
- A. I feel so anxious all the time.
- B. I don't enjoy the things I used to love.
- C. I can't concentrate on anything.
- D. I have trouble sleeping through the night.
Correct Answer: B
Rationale: Anhedonia is the inability to experience pleasure from activities usually found enjoyable. The statement 'I don't enjoy the things I used to love' directly reflects this symptom as the client is expressing a lack of pleasure from previously enjoyable activities. Choices A, C, and D do not specifically relate to anhedonia but rather indicate symptoms of anxiety, concentration difficulties, and sleep disturbances, respectively.
When assessing a client's behavior for potential aggression, what behavior would be recognized as the highest predictor of future violence?
- A. Pacing and restlessness
- B. Verbal threats
- C. History of violence
- D. Substance abuse
Correct Answer: C
Rationale: A history of violence is considered the highest predictor of future violence. Clients who have a history of violent behavior are more likely to engage in violent acts in the future compared to those who exhibit other behaviors such as pacing, making verbal threats, or having substance abuse issues. Understanding a client's history of violence is crucial in assessing the risk of potential aggression and violence. Pacing and restlessness, verbal threats, and substance abuse can be concerning behaviors but do not carry the same predictive value for future violence as a documented history of violent behavior.
A healthcare professional is providing care for a client with a diagnosis of bipolar disorder. Which client behavior would the healthcare professional identify as characteristic of a manic episode?
- A. Sleeping excessively
- B. Excessive energy
- C. Decreased appetite
- D. Lack of interest in activities
Correct Answer: B
Rationale: During a manic episode in bipolar disorder, individuals often experience heightened energy levels, increased goal-directed activity, and may engage in risky behaviors. This excessive energy is a key characteristic of manic episodes. Choice A, sleeping excessively, is more characteristic of a depressive episode. Choice C, decreased appetite, can be seen in various mood disorders but is not specific to manic episodes. Choice D, lack of interest in activities, is more indicative of a depressive episode rather than a manic episode. It is important for healthcare professionals to recognize these signs to provide appropriate care and support to individuals with bipolar disorder.
A healthcare professional is assessing a client diagnosed with body dysmorphic disorder. Which of the following findings should the healthcare professional expect?
- A. Preoccupation with a perceived physical defect
- B. Fear of gaining weight
- C. Excessive worry about physical symptoms
- D. Persistent depressive mood
Correct Answer: A
Rationale: The correct answer is A: Preoccupation with a perceived physical defect. Individuals with body dysmorphic disorder exhibit an obsessive preoccupation with a perceived flaw in their physical appearance, which is often minor or not noticeable to others. This preoccupation causes distress and leads to repetitive behaviors like mirror checking or seeking reassurance about their appearance. Choices B, C, and D are incorrect because fear of gaining weight is more characteristic of an eating disorder, excessive worry about physical symptoms may be seen in somatic symptom disorder, and persistent depressive mood aligns more with depressive disorders rather than body dysmorphic disorder.