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A client reports having difficulty concentrating and outbursts of anger, as well as feeling 'keyed up' all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?
- A. Social phobia
- B. Panic disorder
- C. Post-traumatic stress disorder (PTSD)
- D. Obsessive-compulsive disorder (OCD)
Correct Answer: C
Rationale: PTSD is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Panic disorders and social phobia are characterized by a specific fear of an object or situation. OCD involves some repetitive thoughts or behaviors.
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A client suffering from visual hallucinations calls the nurse to her room and says, 'You need to hurry up and kill all these bugs on the wall before they get on me.' Which response by the nurse is most appropriate?
- A. Why don't you lay down and take a nap?
- B. I don't see them. Can you show me where they are?
- C. I will call maintenance and have them come take care of this right away.
- D. I know the bugs seem real to you, but I don't see anything on the walls.
Correct Answer: D
Rationale: This response acknowledges the client's perception without reinforcing the hallucination, promoting trust and reality orientation.
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
A pregnant client is newly diagnosed with gestational diabetes. The client cries when receiving this information and keeps repeating, 'What have I done to cause this? If only I could live my life over.' Considering this statement, which concern should the nurse identify for the client?
- A. Injury to the fetus because of maternal distress
- B. Low self-esteem because of pregnancy complications
- C. Lack of understanding about diabetic self-care during pregnancy
- D. Poorly perceived body image caused by complications of pregnancy
Correct Answer: B
Rationale: The client is putting the blame for the diabetes on herself, thus lowering her self-esteem. She is expressing fear and grief. There are no data in the question to support the problems in options 1 and 4. Client lack of understanding is important to consider, but not at this time because the client will not be able to comprehend information in her current state.
The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe?
- A. The client is experiencing delusions of messianic grandeur.
- B. The client believes that the world is ending on a specific date.
- C. The client is experiencing persistent pain after the resolution of herpes zoster.
- D. The client is experiencing blindness without an identified physical cause.
Correct Answer: D
Rationale: Conversion disorder involves physical symptoms, like blindness, without a medical cause, often linked to psychological stress. Blindness without a physical cause is a classic example, unlike delusions or unrelated pain.
A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with hyperglycemia. During the assessment, the client states to the nurse, 'I'm sorry to keep bothering you every day, but I just can't give myself those awful shots.' Which therapeutic comment is most appropriate for the nurse to respond?
- A. I couldn't give myself a shot either.
- B. You must learn to give yourself the shots.
- C. Let me see if we can change your medication.
- D. Have you had instructions on injecting yourself?
Correct Answer: D
Rationale: It is important to determine and deal with a client's underlying fear of self-injection. The nurse should determine whether a knowledge deficit exists. Positive reinforcement should occur rather than focusing on negative behaviors. Demanding that the client perform a behavior or skill is inappropriate. The nurse should not offer a change in regimen that cannot be accomplished.