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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 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.
After teaching a group of nursing students about the connections between mental health and medical disorders on clients and families, the instructor determines the need for additional teaching when the students identify which of the following as an effect?
- A. Increased motivation for self-care
- B. Prolonged hospitalization
- C. Delayed recovery
- D. Increased financial strain
Correct Answer: A
Rationale: Increased motivation for self-care (A) is not a typical effect of combined mental health and medical disorders; these conditions often reduce motivation. Prolonged hospitalization (B), delayed recovery (C), and increased financial strain (D) are recognized effects.
A client visits the clinic and complains of chronic pain in her leg as a result of a fall 6 months ago. Which of the following would be most important for the nurse to do first when developing the client?s plan of care?
- A. Acknowledge the client?s pain.
- B. Identify situations that increase the pain.
- C. Have the client rate her pain from 1 to 10.
- D. Review the client?s current medications.
Correct Answer: A
Rationale: Acknowledging the client?s pain (A) is the first step to build trust and validate the client?s experience, essential for effective care planning. Identifying pain triggers (B), rating pain (C), and reviewing medications (D) follow but are secondary to establishing rapport.
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.