Nokea
A client visits the emergency department after she was raped in her apartment. The nurse assesses the client?s ability to adapt to the trauma by assessing her social support systems and which of the following?
- A. Ability to effectively activate coping strategies
- B. Evidence of body image disturbance
- C. Type of affect reflected in nonverbal communication
- D. Degree of fear response reflected in nonverbal communication
Correct Answer: A
Rationale: Assessing the ability to activate coping strategies (A) is critical for evaluating adaptation to trauma, alongside social support. Body image disturbance (B), affect (C), and fear response (D) may be relevant but are less directly tied to adaptive capacity.
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A client has had a major stroke, and she is struggling to adjust to living with the consequent changes and permanent disabilities because of problems related to speech and mobility. The nurse is making a home visit and assesses the client closely based on the understanding that the client is at increased risk for which of the following?
- A. Bipolar I disorder
- B. Major depressive disorder
- C. Generalized anxiety disorder
- D. Posttraumatic stress disorder
Correct Answer: B
Rationale: Major depressive disorder (B) is a common risk following a major stroke due to the impact of speech and mobility impairments on quality of life. Bipolar disorder (A), anxiety (C), and PTSD (D) are less directly associated with stroke-related disability.
A nurse is reviewing the medication history of a client with a medical illness who is also exhibiting signs and symptoms of depression and agitation. Which medications would the nurse identify as possibly contributing to the client?s current state? Select all that apply.
- A. Clonidine
- B. Ibuprofen
- C. Acetaminophen
- D. Baclofen
- E. Carvedilol
Correct Answer: A,D,E
Rationale: Clonidine (A), baclofen (D), and carvedilol (E) can contribute to depression or agitation due to their CNS effects. Ibuprofen (B) and acetaminophen (C) are less likely to cause these psychiatric symptoms.
A client visits the clinic and tells the nurse about experiencing chronic stress on the job for the past 3 months. When teaching the client about chronic stress, which of the following would the nurse include as a possible result?
- A. Lung disorders
- B. Renal disorders
- C. Infections
- D. Thyroid disorders
Correct Answer: C
Rationale: Chronic stress weakens the immune system, increasing susceptibility to infections (C). Lung (A), renal (B), and thyroid disorders (D) are less directly linked to chronic stress, though prolonged stress may exacerbate existing conditions.
A nurse is assessing a client with HIV who has developed HAND. The nurse determines that the client?s extrapyramidal system has been affected when the client exhibits which of the following? Select all that apply.
- A. Ataxia
- B. Inattention
- C. Tremors
- D. Spasticity
- E. Memory loss
Correct Answer: A,C,D
Rationale: HAND can affect the extrapyramidal system, leading to ataxia (A), tremors (C), and spasticity (D). Inattention (B) and memory loss (E) are cognitive symptoms, not specific to extrapyramidal dysfunction.
A nursing instructor is describing how pain can impact a client psychosocially. As part of the discussion, the instructor explains the pain response. Which of the following would the instructor include as excitatory amino acids involved? Select all that apply.
- A. Somatostatin
- B. Substance P
- C. L-glutamate
- D. Serotonin
- E. N-methyl-D-aspartate
- F. Endorphins
Correct Answer: B,C,E
Rationale: Substance P (B), L-glutamate (C), and N-methyl-D-aspartate (E) are excitatory amino acids involved in pain transmission. Somatostatin (A) and endorphins (F) are inhibitory, and serotonin (D) modulates pain but is not an excitatory amino acid.