Nokea
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
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A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.
A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Delayed language development
- B. Spinning a toy repetitively
- C. Ritualistic behavior
- D. Consistent limit testing
Correct Answer: A, B, C
Rationale: Delayed language skills, repetitive behaviors, and a need for routines are common in autism spectrum disorder.
A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?
- A. "You will give up your right to refuse antidepressant medications upon admission."
- B. "Your provider is required to notify your employer of your admission."
- C. "You will still need to give informed consent for treatments after admission."
- D. "You cannot leave the facility until your provider completes a discharge summary."
Correct Answer: C
Rationale: The correct answer is C: "You will still need to give informed consent for treatments after admission." This statement is important to include in teaching because even after being admitted to a mental health facility, the client retains the right to give informed consent for any treatments or interventions. It emphasizes the client's autonomy and involvement in decision-making regarding their care.
The other options are incorrect:
A: "You will give up your right to refuse antidepressant medications upon admission." This statement is incorrect as the client still has the right to refuse specific treatments even after admission.
B: "Your provider is required to notify your employer of your admission." This statement is incorrect as confidentiality laws protect the client's privacy and do not require notification to the employer.
D: "You cannot leave the facility until your provider completes a discharge summary." This statement is incorrect as the client has the right to leave the facility against medical advice, although there may be consequences or processes to follow.
A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)
- A. Grooming
- B. Long-term memory
- C. Support systems
- D. Affect
- E. Presence of pain
Correct Answer: A, B, D
Rationale: The correct choices for the nurse to include in the MSE for a client with dementia are A, B, and D. Grooming is important to assess the client's self-care ability, which can be impacted by dementia. Long-term memory is essential in evaluating cognitive decline typically seen in dementia. Affect assessment helps determine emotional responses and can indicate changes in mood associated with dementia. Support systems (choice C) are not typically part of the MSE but are relevant for treatment planning. Presence of pain (choice E) is important but not a traditional component of a mental status examination.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
- A. "We will call your family in time for them to get here."
- B. "I wonder if you are fearful of dying alone."
- C. "I will make sure a staff member is in your room at all times."
- D. "I will tell your family of your concern so that they can be here."
Correct Answer: B
Rationale: The correct answer is B: "I wonder if you are fearful of dying alone." This response shows empathy and addresses the client's emotional needs. It acknowledges the client's fear and opens up a conversation about their concerns. It allows the client to express their feelings and provides an opportunity for therapeutic communication.
Choice A is incorrect because it only focuses on calling the family and does not address the client's emotional state. Choice C is incorrect as it only ensures physical presence but does not address the client's emotional needs. Choice D is incorrect as it shifts the responsibility to the family without acknowledging the client's feelings.