Nokea
The nurse is caring for a client in whom a psychological disorder is anticipated. Which assessment data would the nurse use to formulate report for the next shift? Select all that apply.
- A. Family history
- B. Mental status examination
- C. Laboratory/diagnostic testing
- D. Client statements
- E. Community report
Correct Answer: A,B,C,D
Rationale: The nurse would use verifiable data to report the client's condition to the next shift. Information from community sources may or may not be accurate.
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The nurse is obtaining a health history from a client with stress-related illnesses. When the nurse asks the client how the client copes with stress, which coping mechanism causes the nurse the most concern?
- A. I play video games for an hour.
- B. I run eight hours per day.
- C. I lift weights after work.
- D. I go out with friends.
Correct Answer: B
Rationale: The nurse is most concerned about the maladaptive coping mechanism of running eight hours per day. Playing video games, exercising or lifting weights, and going out with friends are more positive, beneficial coping mechanisms which, if done appropriately and in moderation, can reduce stress.
The nurse is instructing a community education class on stress. The nurse asks the participants, 'Is all stress bad for you?' Which answer by the participants indicates that teaching has been effective?
- A. No, all stress has negative effects on the body systems.
- B. Yes, all stress is bad but in varying degrees depending on the nature.
- C. No, not all stress is bad, but all stress can make a person sick.
- D. No, the right amount of stress can be motivating to accomplish goals.
Correct Answer: D
Rationale: Teaching has been effective if participants state that not all stress is bad because the right amount of stress can be motivating. Just the right amount of stress, called eustress, is what maintains a healthy balance in life. The other statements are not accurate.
The nurse is using a theory which includes positive reinforcement with rewarding client behavior in group participation activities. From which theorist is the nurse deriving these strategies?
- A. Sigmund Freud
- B. Erik Erikson
- C. Harry Sullivan
- D. B.F. Skinner
Correct Answer: D
Rationale: B.F. Skinner proposed the theory that adaptive and maladaptive behavior are learned and repeated because of rewarding reinforcement. The other theorists listed did not propose such a theory.
What condition triggers the general adaptation syndrome?
- A. Distress
- B. Eustress
- C. Placebo effect
- D. Helplessness
Correct Answer: A
Rationale: Excessive, ill-timed, or unrelieved stress is called distress. It triggers the general adaptation syndrome, a nonspecific physiologic response. Eustress means the right amount of stress and maintains a healthy balance in life. It cannot trigger general adaptation syndrome. The placebo effect refers to healing or improvement that takes place because the person believes a treatment method will be more effective. Helplessness is a psychological factor that makes a client with stress disease prone. It is not a condition that triggers the general adaptation syndrome.
The nurse is caring for a client diagnosed with Parkinson disease. The nurse is most correct to correlate the client's uncontrolled tremors as a physical characteristic of a lack of which neurotransmitter?
- A. Serotonin
- B. Norepinephrine
- C. Dopamine
- D. Acetylcholine
Correct Answer: C
Rationale: Parkinson disease is a neurodegenerative disorder and the most common movement disorder. It is characterized by progressive loss of muscle control, which leads to trembling of the limbs and head while at rest, stiffness, slowness, and imbalance. Low levels of the neurotransmitter dopamine have been linked to the uncontrollable tremors. The other neurotransmitters are not related to Parkinson disease.