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A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?
- A. How long has this been going on?
- B. It sounds like you're having a difficult time.
- C. Why do you think you are so anxious?
- D. Have you talked to your parents about this yet?
Correct Answer: B
Rationale: The correct answer is B. By acknowledging the client's feelings and expressing empathy, the nurse validates the client's experience and shows support. This can help build rapport and trust, leading to better communication and a therapeutic relationship. Option A focuses on the duration of symptoms, which may be important but does not address the immediate emotional needs of the client. Option C may come across as confrontational and put the client on the defensive. Option D assumes the client has not discussed the issue with their parents and may not be appropriate for all clients.
A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has hired a house cleaner.
- B. The partner has placed locks at the top of the doors leading to the outside.
- C. The partner has lost 25 lb in the past 3 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 25 lb in the past 3 months indicates caregiver role strain. Weight loss can be a sign of stress and neglecting one's own needs while caring for someone with Alzheimer's. This choice reflects the physical toll caregiving can take.
A: Hiring a house cleaner (choice A) shows that the partner is seeking help and support, which is a positive coping strategy and does not necessarily indicate caregiver role strain.
B: Placing locks at the top of the doors (choice B) demonstrates safety measures for the client and does not directly indicate caregiver role strain.
D: Redirecting the client when frustrated (choice D) shows appropriate management of challenging behaviors and does not directly indicate caregiver role strain.
In summary, choice C is the best indicator of caregiver role strain as it reflects the physical impact of the caregiving responsibilities on the partner's well-being.
A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?
- A. The client has demonstrated increased impulsive behaviors in the past few weeks.
- B. The client states she wants to go home to be with her children and partner.
- C. The client identifies with problems expressed by other clients.
- D. The client has begun playing basketball with several other clients during the past month.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Increased impulsive behaviors in bipolar disorder may indicate heightened risk for suicide due to poor impulse control.
2. Impulsivity is a known risk factor for suicidal behavior in individuals with bipolar disorder.
3. Impulsive actions can lead to reckless behaviors that may result in self-harm or suicide.
4. Monitoring and addressing impulsivity is crucial in assessing suicide risk in clients with bipolar disorder.
Incorrect Choices:
B. Wanting to be with family is a protective factor, reducing suicide risk.
C. Identifying with others' problems may indicate empathy but does not directly suggest suicide risk.
D. Engaging in group activities like basketball is a positive coping strategy and does not inherently indicate suicide risk.
Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.