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A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?
- A. Offering hope allays and defuses the patient's anxiety.
- B. Concerns stated aloud become less overwhelming and help problem solving begin.
- C. Anxiety is reduced by focusing on and validating what is occurring in the environment.
- D. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
Correct Answer: B
Rationale: The correct answer is B because verbalizing feelings and concerns can help the patient process and understand their emotions, making them feel less overwhelming. This can facilitate problem-solving by breaking down complex issues into smaller, manageable parts. By talking about their concerns, the patient can also receive support and feedback from the nurse, leading to a sense of relief and empowerment.
Incorrect answer explanations:
A: Offering hope may be comforting but does not directly address the patient's current anxiety by helping them process and verbalize their feelings.
C: Focusing on the environment may not necessarily address the patient's internal feelings and concerns, which are key in managing anxiety.
D: While exploring alternatives can increase a sense of control, it may not directly address the immediate need to process and verbalize emotions to reduce anxiety.
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After describing the various legislative efforts to address the issue of homelessness in the United States, a nursing instructor determines that the teaching was successful when the students identify which of the following as addressing the need for a continuum of care approach?
- A. Bringing Home America Act
- B. Affordable Care Act
- C. American Recovery and Reinvestment Act
- D. McKinney-Vento Homeless Assistance Act
Correct Answer: D
Rationale: The correct answer is D: McKinney-Vento Homeless Assistance Act. This act addresses the need for a continuum of care approach by providing federal funding for homeless assistance programs that offer a range of services to individuals experiencing homelessness. It emphasizes the importance of coordination among various service providers to ensure a seamless transition from emergency shelters to permanent housing.
Choice A: Bringing Home America Act does not specifically focus on homeless assistance programs or the continuum of care approach.
Choice B: Affordable Care Act primarily focuses on healthcare reform and expanding access to healthcare services, not specifically related to addressing homelessness.
Choice C: American Recovery and Reinvestment Act aims to stimulate economic recovery through job creation and infrastructure projects, not directly related to addressing homelessness or providing a continuum of care approach.
A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority?
- A. Self-esteem–building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide precautions
Correct Answer: D
Rationale: The correct answer is D: Suicide precautions. The patient's statement indicates suicidal ideation and intent. Priority is to ensure immediate safety. Suicide precautions involve continuous monitoring, removing harmful objects, and providing a safe environment. A: Self-esteem activities, B: Anxiety measures, and C: Sleep enhancement are important, but not the priority when a patient is at risk of self-harm.
A twenty-eight-year-old client enters the family therapy meeting clutching a blanket and holds the blanket throughout the session while rocking back and forth in the chair. What defense mechanism is the client demonstrating?
- A. denial
- B. projection
- C. undoing
- D. regression
Correct Answer: D
Rationale: The correct answer is D: regression. The client clutching a blanket and rocking back and forth indicate a return to an earlier stage of development to cope with stress or anxiety. Regression involves reverting to behaviors from a less mature stage. Denial (A) involves refusing to acknowledge reality, projection (B) involves attributing one's feelings onto others, and undoing (C) involves trying to undo or reverse an unacceptable action or thought. These defense mechanisms do not align with the client's behavior of regression.
A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication would the nurse expect to most likely administer?
- A. Lithium carbonate (Lithium)
- B. Haloperidol lactate (Haldol)
- C. Fluoxetine (Prozac)
- D. Paroxetine (Paxil)
Correct Answer: B
Rationale: The correct answer is B: Haloperidol lactate (Haldol). In the acute phase of mania, antipsychotic medications like haloperidol are commonly used to manage symptoms such as agitation, hyperactivity, and psychosis. Haloperidol helps to reduce dopamine activity in the brain, which can help stabilize mood and behavior during manic episodes. Lithium (A) is more commonly used for long-term mood stabilization in bipolar disorder. Fluoxetine (C) and Paroxetine (D) are selective serotonin reuptake inhibitors (SSRIs) used for depression and not recommended during mania due to the risk of worsening manic symptoms.
A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?
- A. The client has surgical hypoparathyroidism and positive Trousseau's sign.
- B. A client who has Clostridium difficile with acute diarrhea
- C. A client who is experiencing acute kidney injury and has urine with a low specific gravity
- D. The client who has oral cancer and reports a sore on his gums
Correct Answer: A
Rationale: The correct answer is A because the client with surgical hypoparathyroidism and positive Trousseau's sign indicates a potential life-threatening condition due to hypocalcemia. Trousseau's sign is a clinical indicator of hypocalcemia, which can lead to serious complications such as seizures and tetany. This client needs immediate intervention to prevent further complications.
Choice B is incorrect because while Clostridium difficile with acute diarrhea requires prompt treatment, it is not as immediately life-threatening as hypocalcemia. Choice C is incorrect as well, as although acute kidney injury is serious, a low specific gravity alone does not necessarily indicate an immediate threat to the client's life. Choice D is also incorrect as oral cancer with a sore on the gums, while concerning, is not an immediate priority compared to the potential life-threatening complications of hypocalcemia.