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If a diagnosis of panic disorder is accurate, the nurse would correctly assume that the chest pain is related to which cause?
- A. Unknown cause
- B. Feigned illness
- C. Attention-seeking behavior
- D. Intense fear
Correct Answer: D
Rationale: Chest pain in panic disorder results from intense fear, which triggers physical symptoms like muscle tension and hyperventilation.
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If the home health nurse documented all of the following findings, which one is most suggestive that the client is depressed?
- A. The client is irritable after grandchildren visit.
- B. The client has multiple, unrelated physical complaints.
- C. The client takes lengthy naps in the late afternoon.
- D. The client cries when talking about a dead spouse.
Correct Answer: B
Rationale: Multiple somatic complaints are a hallmark of depression in older adults, often masking emotional symptoms.
The nurse suspects that a coworker is working while impaired. Which initial action should be taken by the nurse?
- A. Contact the Drug Enforcement Agency (DEA).
- B. Contact the nurse manager to report the incident.
- C. Confront the nurse and suggest that the nurse “get help.”
- D. File an anonymous report with the state’s board of nursing.
Correct Answer: B
Rationale: Reporting to the nurse manager (B) initiates investigation. DEA (A) is for diversion confronting (C) risks denial board reporting (D) follows manager.
The nurse is educating the client on the methadone prescribed for replacement therapy while in an outpatient treatment program for heroin addicts. The client asks how taking a pill is going to help the client stay substance-free. Which statement is the nurse’s best reply?
- A. “The methadone will give you the same high so you won’t want heroin anymore.”
- B. “The methadone will cause you to become very sick if you take heroin at the same time”
- C. “The methadone ‘replaces’ heroin in your body so you will have fewer cravings for heroin.”
- D. “The methadone causes sedation; you’ll sleep better so you can participate in your treatment.”
Correct Answer: C
Rationale: Methadone displaces heroin reducing cravings (C). It doesn’t produce a high (A) cause sickness (B) or sedate (D).
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
The nurse manager concerned about the potential for staff harm on a behavioral health unit is assessing the unit’s milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?
- A. Two clients have a history of spousal abuse.
- B. Several clients have lost smoking privileges.
- C. The unit is currently at less than full client capacity.
- D. The nurse from a medical unit is assigned to work on the unit.
Correct Answer: D
Rationale: Staff inexperience (D) predicts violence. Client history (A) and privileges (B) are client-focused and low capacity (C) reduces not increases risk.