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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. Depersonalization
- D. Euphoric mood
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, clients often experience restlessness due to excessive worry and fear. This can manifest as fidgeting, inability to relax, and feeling on edge. Restlessness is a common symptom seen in individuals with this disorder. Increased energy (choice A) is less likely as anxiety tends to deplete energy. Depersonalization (choice C) is more commonly associated with dissociative disorders, not generalized anxiety disorder. Euphoric mood (choice D) is not typically seen in clients with generalized anxiety disorder, as they are more likely to feel tense and worried.
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A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements?
- A. I want to learn how to change the way I react to problems within my family
- B. I want to understand why my past experiences are affecting my family relationships
- C. I want to improve my family’s understanding of each other’s boundaries
- D. I want each of my family members to be more aware of each other’s feelings
Correct Answer: A
Rationale: The correct answer is A because cognitive behavioral family therapy focuses on changing negative thought patterns and behaviors. By wanting to change the way they react to family problems, the client is demonstrating a readiness to engage in cognitive restructuring and behavioral change. Choice B is incorrect as it pertains more to individual therapy exploring past experiences. Choice C is incorrect as it focuses on improving understanding of boundaries, which is not the primary goal of cognitive behavioral family therapy. Choice D is incorrect because it emphasizes awareness of feelings rather than addressing reactive behaviors.
A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse in a psychiatric unit is providing discharge instructions to a client who has schizophrenia and a new prescription for clozapine. Which of the following statements should the nurse include?
- A. Get up quickly from a sitting or lying position
- B. Expect to have an increased risk of infection
- C. Avoid exposure to sunlight
- D. Limit fluid intake
Correct Answer: B
Rationale: The correct answer is B: Expect to have an increased risk of infection. Clozapine is known to suppress the immune system, increasing the risk of infections. The nurse should educate the client to monitor for signs of infection, practice good hygiene, and promptly report any symptoms of infection to their healthcare provider.
Choice A is incorrect because getting up quickly can lead to orthostatic hypotension, a common side effect of clozapine. Choice C is incorrect as clozapine does not specifically require avoiding sunlight. Choice D is incorrect as limiting fluid intake is not a requirement for clozapine.
A nurse in a psychiatric unit is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take?
- A. Allow the client to perform compulsive rituals
- B. Discourage discussion about the compulsions
- C. Encourage the client to use thought-stopping techniques
- D. Limit the client’s decision-making opportunities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use thought-stopping techniques. This is because thought-stopping techniques are a common cognitive-behavioral intervention used to help individuals with obsessive-compulsive disorder interrupt and replace their distressing thoughts or compulsive behaviors with healthier alternatives. By encouraging the client to use these techniques, the nurse can help the client develop coping strategies to manage their symptoms effectively.
Choices A, B, and D are incorrect because they do not address the core issue of obsessive-compulsive disorder and may even exacerbate the client's symptoms. Allowing the client to perform compulsive rituals reinforces maladaptive behaviors, discouraging discussion about the compulsions limits the client's ability to seek support and understanding, and limiting decision-making opportunities may increase the client's anxiety and feelings of lack of control.