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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. 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.
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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 is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse administer?
- A. Methadone
- B. Chlordiazepoxide
- C. Naltrexone
- D. Disulfiram
Correct Answer: B
Rationale: The correct answer is B: Chlordiazepoxide. This medication is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, agitation, and preventing seizures. Benzodiazepines help to stabilize the central nervous system during alcohol withdrawal, making it the appropriate choice for this client.
Incorrect Choices:
A: Methadone is used for opioid withdrawal, not alcohol withdrawal.
C: Naltrexone is used for alcohol dependence treatment by reducing cravings, not for acute withdrawal symptoms.
D: Disulfiram is used as a deterrent for alcohol consumption, not for managing withdrawal symptoms.
A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
A nurse is assessing a client who has been taking clozapine for 3 months. Which of the following findings should the nurse report to the provider immediately?
- A. Constipation
- B. Sore throat
- C. Dry mouth
- D. Drowsiness
Correct Answer: B
Rationale: The correct answer is B: Sore throat. Clozapine can cause agranulocytosis, a serious condition characterized by a low white blood cell count, which can manifest as sore throat, fever, or flu-like symptoms. Immediate reporting is crucial to monitor for potential complications. Constipation (A), dry mouth (C), and drowsiness (D) are common side effects of clozapine but do not require immediate reporting unless severe.
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills?
- A. How does this situation affect your life?
- B. Do you see your current situation affecting your future?
- C. Can you describe how you are currently feeling?
- D. How have you dealt with similar situations in the past?
Correct Answer: D
Rationale: The correct answer is D: How have you dealt with similar situations in the past? This question assesses the client's personal coping skills by exploring their past strategies for managing challenging situations. By understanding their previous coping mechanisms, the nurse can identify effective approaches to support the client in managing their current depression.
A: How does this situation affect your life? - This question focuses on the impact of the current situation but does not directly assess the client's coping skills.
B: Do you see your current situation affecting your future? - This question explores the client's perspective on the influence of the situation on their future, but it does not specifically address coping skills.
C: Can you describe how you are currently feeling? - This question evaluates the client's emotional state but does not directly assess coping skills.