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A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?
- A. Reaction formation.
- B. Somatization.
- C. Sublimation.
- D. Intellectualization.
Correct Answer: B
Rationale: Somatization involves the transformation of anxiety into physical symptoms, such as pain or fatigue, without a medical cause. This is a way the body expresses psychological distress through physical symptoms, aligning with the client’s behavior.
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A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
- A. Fluctuating level of orientation.
- B. Consistent state of depression.
- C. Demonstrates obsessive behaviors.
- D. Short-term memory loss.
Correct Answer: A
Rationale: A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention and cognition, distinguishing it from depression or dementia.
A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Cold extremities.
- B. Diarrhea.
- C. Tooth erosion.
- D. Lanugo.
Correct Answer: A,C,D
Rationale: Cold extremities, tooth erosion, and lanugo are common in anorexia nervosa. Poor circulation causes cold extremities, vomiting erodes teeth, and lanugo grows to conserve heat due to fat loss, reflecting the disorder’s physical impact.
A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?
- A. Everyone feels depressed during the grieving process.
- B. I remember how depressed I was after my friend died.
- C. You should start participating in your usual activities.
- D. Tell me what your relationship with your partner was like.
Correct Answer: D
Rationale: Asking about the client’s relationship encourages them to express their feelings and helps the nurse understand their experience to provide support. This fosters a therapeutic dialogue.
A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?
- A. Provide the client with a dark environment for sleeping.
- B. Repeat orientation tasks until the client gives a correct response.
- C. Give the client a list of foods to choose from for dinner.
- D. Make a personal introduction to the client at each interaction.
Correct Answer: D
Rationale: Making a personal introduction at each interaction helps establish connection and reduce confusion for clients with dementia, who often have short-term memory loss.