Nokea
A client with heart disease who had a myocardial infarction 2 months ago comes to the clinic for a follow-up visit. While assessing the client, the nurse would be alert most likely for the development of which of the following responses? Select all that apply.
- A. Personality disorder
- B. Depression
- C. Substance abuse disorder
- D. Anxiety disorder
- E. Delirium
Correct Answer: B,D
Rationale: Depression (B) and anxiety disorder (D) are common post-myocardial infarction due to emotional and physical stress. Personality disorders (A) are not typically triggered, substance abuse (C) is less directly linked, and delirium (E) is more acute and less likely 2 months post-event.
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A group of nursing students is reviewing information about barriers to pain management. The group demonstrates the need for additional study when they identify which of the following as a barrier?
- A. Fear of tolerance
- B. Adequate reimbursement
- C. Concern for being a good client
- D. Reluctance to report pain
Correct Answer: B
Rationale: Adequate reimbursement (B) is not a barrier to pain management; it facilitates access to care. Fear of tolerance (A), concern for being a 'good client' (C), and reluctance to report pain (D) are recognized barriers due to patient fears and behaviors.
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 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.
A nurse is trying to determine whether a client is exhibiting symptoms of depression or of her medical illness. Which of the following group of symptoms would indicate to the nurse that the client may be experiencing depression in addition to being medically ill?
- A. Problems sleeping, decreased appetite, and frequent crying
- B. Low self-esteem, decreased appetite, and problems sleeping
- C. Feeling guilty, difficulty making decisions, and low self-esteem
- D. Loss of energy, difficulty making decisions, and problems sleeping
Correct Answer: C
Rationale: Feeling guilty, difficulty making decisions, and low self-esteem (C) are specific to depression, distinguishing it from medical illness symptoms like sleep issues or appetite changes (A, B, D), which can overlap with physical conditions.
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.