Nokea
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Euphoric mood
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, individuals often experience restlessness due to persistent worry and fear. This can manifest as physical agitation and an inability to relax. Increased energy (A) is not typically associated with generalized anxiety disorder, as individuals may feel fatigued due to constant worrying. Euphoric mood (C) is more characteristic of conditions like bipolar disorder, not generalized anxiety disorder. Depersonalization (D) involves feeling detached from oneself and is more commonly associated with conditions like dissociative disorders, not generalized anxiety disorder.
You may also like to solve these questions
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include?
- A. Provide frequent rest periods
- B. Discourage social interaction
- C. Allow unlimited physical activity
- D. Limit the client's choices
Correct Answer: A
Rationale: The correct answer is A: Provide frequent rest periods. During mania, clients with bipolar disorder have high energy levels and may engage in excessive activities, leading to physical and mental exhaustion. Providing frequent rest periods helps to prevent burnout and promotes relaxation. Choice B is incorrect as social interaction can provide support and prevent feelings of isolation. Choice C is incorrect as unlimited physical activity can exacerbate manic symptoms. Choice D is incorrect as limiting choices can cause frustration and may escalate the manic episode.
A nurse is caring for a client in the emergency department who states she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
- A. Conduct a pregnancy test
- B. Request mental health consultation for the client
- C. Provide a trained advocate to stay with the client
- D. Offer prophylactic medication to prevent STI’s
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A
Rationale: The correct answer is A: Conduct a pregnancy test. This action is important to assess the client's risk of pregnancy resulting from the sexual assault. Pregnancy testing is crucial for timely decision-making regarding emergency contraception. This step is a priority in the care of a sexual assault survivor. It ensures appropriate medical intervention and support for the client's physical and emotional well-being.
Summary of other choices:
B: Requesting mental health consultation is important but not the immediate next step.
C: Providing a trained advocate is valuable for support but does not address the urgent medical needs of the client.
D: Offering prophylactic medication for STIs is important but not the immediate next step before assessing pregnancy risk.
E: This choice is unrelated to the situation described and should not be considered in this context.
A nurse is teaching the parent of a school-age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching?
- A. Expect the child to gain weight while taking this medication
- B. Crush the medication and mix it with 120 mL (4 oz) of juice
- C. Therapeutic effects will occur within 24 hr of starting treatment
- D. Administer the medication before the child goes to school in the morning
Correct Answer: D
Rationale: The correct answer is D: Administer the medication before the child goes to school in the morning. Atomoxetine is a non-stimulant medication used to treat ADHD. Administering it in the morning allows for optimal absorption and effectiveness during the school day. This helps in improving the child's focus and attention span in a learning environment. Additionally, taking the medication in the morning helps in minimizing potential side effects such as insomnia. Choices A, B, and C are incorrect because weight gain is not a common side effect of atomoxetine, crushing the medication can alter its effectiveness, and therapeutic effects usually take a few weeks to manifest, not within 24 hours.
A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse’s priority at this time?
- A. Contact the adolescent’s parents
- B. Suggest the adolescent join support groups
- C. Ask the adolescent if he is considering hurting himself
- D. Determine when the adolescent’s change in behavior began
Correct Answer: C
Rationale: The correct answer is C: Ask the adolescent if he is considering hurting himself. This is the priority intervention because it addresses the immediate safety and well-being of the adolescent. By directly asking about thoughts of self-harm, the nurse can assess the risk of suicide and provide appropriate interventions if necessary. Contacting the parents (choice A) can be important but not the priority in this situation. Suggesting support groups (choice B) and determining when the behavior changes began (choice D) are important steps but not as urgent as assessing for suicidal ideation.
A nurse is planning care for a client who has a history of alcohol use disorder and is experiencing withdrawal. Which of the following interventions should the nurse include in the plan?
- A. Administer disulfiram
- B. Monitor for seizures
- C. Restrict fluid intake
- D. Provide a high-protein diet
Correct Answer: B
Rationale: The correct answer is B: Monitor for seizures. During alcohol withdrawal, clients are at risk for seizures due to central nervous system hyperexcitability. Monitoring for seizures allows for prompt intervention if they occur. Administering disulfiram (A) is used to deter alcohol consumption, not for withdrawal. Restricting fluid intake (C) can worsen dehydration, while providing a high-protein diet (D) is not a priority during alcohol withdrawal.