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A nurse is assessing a patient diagnosed with generalized anxiety disorder. The patient reports feeling tense and unable to relax. Which of the following is the priority nursing diagnosis?
- A. Ineffective coping
- B. Anxiety
- C. Risk for injury
- D. Imbalanced nutrition: Less than body requirements
Correct Answer: B
Rationale: Anxiety is the primary symptom of generalized anxiety disorder, and it is the most appropriate nursing diagnosis for this patient.
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A nurse is preparing a client for electroconvulsive therapy (ECT). Which of the following client statements indicates an understanding of the procedure?
- A. This procedure will cause me to have brief seizures.'
- B. I will be able to eat breakfast prior to my procedure.'
- C. I will not need to have a pre-ECT workup before the procedure.'
- D. One ECT treatment will be effective for my depression.'
Correct Answer: A
Rationale: Electroconvulsive therapy (ECT) involves inducing brief seizures under controlled conditions. The client's statement about having brief seizures indicates an understanding of the procedure.
A nurse is assessing a patient diagnosed with major depressive disorder. The patient expresses feelings of hopelessness and states, 'I don't think anything will ever improve.' What is the priority nursing intervention?
- A. Encourage the patient to engage in activities that improve mood.
- B. Assess the patient for suicidal thoughts and ideation.
- C. Provide the patient with positive affirmations and reassurances.
- D. Suggest that the patient take medications to help with their depression.
Correct Answer: B
Rationale: The priority intervention is to assess the patient's risk for suicide, as feelings of hopelessness can indicate a high risk for self-harm. Immediate action is necessary to ensure safety.
Nursing physical assessment of a patient with bulimia often reveals:
- A. Prominent parotid glands.
- B. Peripheral edema.
- C. Thin, brittle hair.
- D. Amenorrhea.
Correct Answer: A
Rationale: Repeated vomiting in bulimia causes parotid gland enlargement (Option A) due to salivary stimulation, per DSM-5. Edema (B), hair changes (C), and amenorrhea (D) are more typical of anorexia.
A nurse is working with a patient diagnosed with generalized anxiety disorder. Which of the following interventions is most appropriate to help the patient manage their anxiety?
- A. Encourage the patient to confront their fears directly.
- B. Provide the patient with relaxation techniques such as deep breathing.
- C. Reassure the patient that their anxiety is not warranted.
- D. Encourage the patient to avoid stressful situations whenever possible.
Correct Answer: B
Rationale: Teaching relaxation techniques, such as deep breathing, helps the patient manage their anxiety by reducing physiological symptoms of anxiety.
A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? (Select all that apply.)
- A. Female
- B. Reports frequent syncope
- C. Rates pain as "1" on a scale of "10"
- D. First diagnosed with psoriasis at age 12
Correct Answer: A
Rationale: There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain.