Nokea
The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.
- A. Preoccupation.
- B. Reexperience.
- C. Somatization.
- D. Disorganization.
Correct Answer: C
Rationale: Somatization involves psychological distress manifesting as physical symptoms like numbness and tingling, likely due to grief. Other options are less applicable.
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A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
- A. Ask the client why she checks the locks.
- B. Determine the type and size of the locks.
- C. Discuss checking the time frequently.
- D. Plan a list of activities to be carried out daily.
Correct Answer: D
Rationale: Planning daily activities redirects focus from compulsive checking, reducing anxiety and improving function, suitable for OCD-like behaviors.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
History and Physical
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and not able to go for her scheduled dialysis 2
On further assessment, the client reports that her doctor had recently started her on Lisinopril for blood pressure control but it "doesn't seem to help". She then complained of some chest discomfort. The client is moved to an ED room, and another set of vital signs is performed. Physician notified and orders received
Which of the following physician's orders requires priority attention from the nurse? Select all that apply.
- A. Basic metabolic panel
- B. Echocardiogram
- C. CT scan of abdomen
- D. Blood cultures times 2 sets
- E. Chest X-ray
- F. Place on a continuous cardiac monitor
- G. CBC
Correct Answer: E,F
Rationale: Chest X-ray and continuous cardiac monitoring are priorities to assess chest discomfort and potential arrhythmias in a client with CAD and hyperkalemia risk. Other orders are important but less urgent.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.