A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior?
- A. Automatic obedience
- B. Waxy flexibility
- C. Negativism
- D. Impaired impulse control
Correct Answer: C
Rationale: The correct answer is C: Negativism. Negativism is a behavior where the client does the opposite of what is asked or expected. In this case, the client with schizophrenia consistently does the opposite of what the nurse asks, which aligns with negativism. Automatic obedience (A) is when a client complies without question, waxy flexibility (B) is characterized by maintaining limbs in the position they are placed in, and impaired impulse control (D) involves difficulty controlling impulses, none of which fit the scenario described.
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A nurse is assessing a client experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Increased energy
- C. Increased cognitive awareness
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Chronic stress can lead to the release of stress hormones like cortisol and adrenaline, which can increase blood sugar levels. This occurs due to the body's fight-or-flight response to stress. Hypotension (A) is unlikely as stress typically leads to increased blood pressure. Increased energy (B) is less likely as chronic stress can lead to fatigue and exhaustion. Increased cognitive awareness (C) is not a common finding in chronic stress, as it can impair cognitive function. Hyperglycemia (D) is the most likely finding due to the physiological response to stress.
A nurse is providing teaching for a client who has binge-eating disorder and is morbidly obese. The client has been prescribed orlistat. Which of the following statements indicates to the nurse that the client understands the teaching?
- A. "I will take my dose of orlistat every morning an hour before breakfast."
- B. "I will stop taking orlistat and call my doctor if my urine gets darker in color."
- C. "I will eat a no-fat diet to prevent side effects from the medication."
- D. "I will feel less hungry during meals while I am taking orlistat."
Correct Answer: B
Rationale: The correct answer is B: "I will stop taking orlistat and call my doctor if my urine gets darker in color." This statement indicates understanding because dark urine can be a sign of liver injury, a serious side effect of orlistat. The client recognizing this symptom and knowing to contact the doctor promptly demonstrates comprehension of the medication's potential risks.
A: "I will take my dose of orlistat every morning an hour before breakfast." - This statement does not indicate understanding of the medication's specific instructions.
C: "I will eat a no-fat diet to prevent side effects from the medication." - While a low-fat diet is recommended with orlistat, this statement does not address potential serious side effects.
D: "I will feel less hungry during meals while I am taking orlistat." - This statement does not address the medication's side effects or potential risks.
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.