Which nursing intervention would help a client who exhibits physical symptoms when stressed

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Performance

Mental Health Week 6: Anxiety

Due Feb 16, 2022 by 11:59 pm

Final Score

100%

103 out of 127 questions answered correctly

Completed on Feb 19, 2022 11:07 am

Incorrect (24)

Which behavior would the nurse expect when caring for a hospitalized

4-year-old child?

Refusing to cooperate with nurses during the parents’ absence

Demonstrating despair if the parents do not visit at least once a week

Crying when the parents leave and return but not during their absence

Avoiding interacting and playing with peers in the playroom if other parents

are present

Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder

Social isolation r/t self directed anger

Which client statement is evidence of the etiology of major depressive disorder from a genetic perspective?

My maternal grandmother was diagnosed with bipolar affective disorder

During an intake assessment, which client statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective?

I don't know about my biological family I was in foster care as an infant

Which statement about the development of bipolar disorder is from a biochemicl perspective?

In bipolar disorder, there may be possible alterations in normal electrolyte transfers

What statement describes a major difference between a client dignosed with major depressive disorder and a client diagnosed with dysthymic disorder

A client diagnosed with dysthymic disorder has symptoms for at least 2 years

A client expresses frustration and hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. Which stage of grief is this?

A client plans and follows thru with the wake and buriall of a child lost in an auto accident.

What charting entry most accurately documents a clients mood?

The client rates mood 2 out of 10

Which client is at highest risk for the diagnosis of major depressive disorders?

24 year old married woman

A client is admitted to an inpatient pscyh unit with a dx of major depressive disorder. Which of the following would the nurse expect to assess? Select all:

Loss of interest
Change in body weight
Psychomotor retardation
Insomnia/hypersomnia

A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms?

Became irritable and agitated on waking

Which symptom is an example of physiological alterations exhibited by clients diag- nosed with moderate depression?

Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression?

Major depressive disorder would be most difficult to detect in which of the following clients?

Which is the key to understanding if a child or adolescent is experiencing an underlying depressive disorder?

A change in behaviors over a 2 week period

The nurse in the emergency department is assessing a client suspected of being suicidal. Number the following assessment questions, beginning with the most critical and ending with the least critical.

are you thinking, plan?, means?, family/friends?

Which nursing charting entry is documentation of a behavioral symptom of mania?

Pacing halls throughout the day. Exhibits poor impulse control.

A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first?

A client pacing the hall and experiencing irritability and flight of ideas.

A nurse is planning to teach about appropriate coping skills. The nurse would expect which client to be at the highest level of readiness to participate in this instruction?

A client admitted 6 days ago for suicidal ideations following a depressive episode.

A newly admitted client has been diagnosed with major depressive disorder. Which nursing diagnosis takes priority?

Risk for self directed violence r/t depressed mood

A client’s outcome states, “The client will make a plan to take control of one life situation by discharge.” Which nursing diagnosis documents the client’s problem that this outcome addresses?

Which nursing diagnosis takes priority for a client immediately after electroconvulsive therapy (ECT)?

Risk for injury r/t altered mental status

A client diagnosed with major depressive disorder has been newly admitted to an in-patient psychiatric unit. The client has a history of two suicide attempts by hanging. Which nursing diagnosis takes priority?

Risk for suicide R / T history of attempts

A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority?

Disturbed sleep patterns R / T agitation.

A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time?

Risk for violence: other-directed R / T poor impulse control.

A client admitted with major depressive disorder has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client

The client will sleep 6 to 8 hours at night by day 5

Which client would the charge nurse assign to an agency nurse working on the inpatient psychiatric unit for the first time?

A client rating mood as 3/10 and attending but not participating in group therapy.

A client has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome, based on this diagnosis, would the nurse prioritize?

The client will remain free from injury throughout hospitalization.

A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate?

The client will distinguish reality from delusions by day 6

A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expectation for this client problem?

The client will have an appropriate 1:1 interaction with a peer by day 4

A suicidal Jewish-American client is admitted to an in-patient psychiatric unit 2 days after the death of a parent. Which intervention must the nurse include in the care of this client?

Allow the client time to mourn the loss during this time of shiva.

A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first?

Complete a thorough physical assessment including lab tests

A client diagnosed with major depressive disorder has a nursing diagnosis of low self-esteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this client’s problem?

Focus on strengths and accomplishments to minimize failures.

A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship?

Sit with the client and offer self frequently.

A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize?

Discuss with the client and family expected short-term memory loss.

Which intervention takes priority when working with newly admitted clients experiencing suicidal ideations

Monitor the client at close, but irregular, intervals.

A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority

Determine if the client has a specific plan to commit suicide.

A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse’s priority intervention?

Assess vital signs, and complete physical assessment.

A client experiencing mania states, “Everything I do is great.” Using a cognitive approach, which nursing response would be most appropriate

"Is there a time in your life when things didn’t go as planned?”

A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client’s a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client?

Chicken fingers and French fries.

A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation?

Privately discuss with the client the inappropriateness of provocative dress during hospitalization.

A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority?

Calmly redirect and remove the client from the milieu.

A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate?

Use PRN antipsychotic medications as ordered by the physician.

A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply.

Financial and legal assistance
Crisis hotline
Individual psychotherapy
Support groups
Family education groups

A nursing student is studying major depressive disorder. Which student statement indicates that learning has occurred?

“Major depression is a leading cause of disability in the United States.”

A client has a nursing diagnosis of dysfunctional grieving R / T loss of a job AEB inability to seek employment because of sad mood. Which would support a resolution of this client’s problem?

The client recognizes and accepts the role he or she played in the loss of the job.

A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders

“Evidence continues to support multiple causations related to an individual’s susceptibility to mood symptoms.

A nursing instructor is presenting statistics regarding suicide. Which student statement indicates that learning has occurred?

“Almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder.”

A client diagnosed with major depressive disorder has an outcome that states, “The client will verbalize a measure of hope about future by day 3.” Which client statement indicates this outcome was successful?

“I think I am going to talk to my boss about conflicts at work.”

A nursing instructor is teaching about the psychosocial theory related to the development of bipolar disorder. Which student statement would indicate that learning has occurred?

“The etiology of bipolar disorder is unclear, but it is possible that biological and psy- chosocial factors are influential.”

A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client’s use of grandiosity. Which is the rationale for this nurse’s action?

Understanding the reason behind a behavior would assist the nurse to accept and relate to the client, not the behavior.

A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred?

Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania.

Which of the following medications may be administered before electroconvulsive therapy? Select all that apply.

(Robinul). (Pentothal). (Anectine).

A client diagnosed with major depressive disorder is prescribed phenelzine (Nardil). Which teaching should the nurse prioritize?

Instruct the client and family about the many food-drug and drug-drug interactions.

A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms?

(Risperdal) and (Lamictal).

A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client’s lithium serum level would be which of the following?

A client diagnosed with major depressive disorder is newly prescribed sertraline (Zoloft). Which of the following teaching points would the nurse review with the client? Select all that apply.

-Discuss the need to take medications, even when symptoms improve. -Instruct the client about the risks of abruptly stopping the medication. -Alert the client to the risks of dry mouth, sedation, nausea, and sexual side effects. -Remind the client that the medication’s full effect does not occur for 4 to 6 weeks.

Which symptoms would the nurse expect to assess in a client suspected to have serotonin syndrome?

Alterations in mental status, restlessness, tachycardia, labile blood pressure, and diaphoresis.

Which medication would be classified as a tricyclic antidepressant?

From a cognitive theory perspective, which is a possible cause of panic disorder?

Distorted thinking patterns that precede maladaptive behaviors.

A client diagnosed with posttraumatic stress disorder is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of posttrau- matic stress disorder was effective?

“I understand that the event I experienced, how I deal with it, and my support system all affect my disease process.”

Which of the following statements explains the etiology of obsessive-compulsive disorder (OCD) from a biological theory perspective?

Abnormalities in various regions of the brain have been implicated in the cause of OCD.

A client diagnosed with social phobia has an outcome that states, “Client will voluntar- ily participate in group activities with peers by day 3.” Which would be an appropriate intrapersonal intervention by the nurse to assist the client to achieve this outcome?

Encourage discussion about fears related to socialization.

Using psychodynamic theory, which intervention would be appropriate for a client diagnosed with panic disorder?

Discuss the overuse of ego defense mechanisms and their impact on anxiety.

Which nursing diagnosis reflects the intrapersonal theory of the etiology of obsessive- compulsive disorder?

Ineffective coping R / T punitive superego.

The nurse is using an intrapersonal approach to assist a client in dealing with survivor’s guilt. Which intervention would be appropriate?

Encourage expression of feelings during one-to-one interactions with the nurse.

A client diagnosed with posttraumatic stress disorder states to the nurse, “All those won- derful people died, and yet I was allowed to live.” Which is the client experiencing?

Clients diagnosed with obsessive-compulsive disorder commonly use which mechanism?

Which charting entry documents a subjective assessment of sleep patterns?

“Reports satisfaction with the quality of sleep since admission.”

Which is important when assessing an individual for a sleep disturbance?

Check the chart to note the client’s baseline sleeping habits per night.

Which of the following situations is a common reason for the elderly to experience sleep disturbances? Select all that apply.

Discomfort or pain or both.
Dementia.

Inactivity.
Anxiety.
Medications.

A client has been diagnosed with insomnia. Which of the following data would the nurse expect to assess? Select all that apply.

Daytime irritability.
Problems with attention and concentration.

Inappropriate use of substances.

What is the most common form of breathing-related sleep disorders?

Which would the nurse expect to assess in a client suspected to have sleep terror disorder?

The client experiences an abrupt arousal from sleep with a piercing scream or cry.

Which of the following would the nurse expect to assess in a client diagnosed with posttraumatic stress disorder? Select all that apply.

Dissociative events.
Intense fear and helplessness.

Avoidance of activities that are associated with the trauma.

When treating individuals with posttraumatic stress disorder, which variables are included in the recovery environment?

Availability of social supports.

A newly admitted client is diagnosed with posttraumatic stress disorder. Which behav- ioral symptom would the nurse expect to assess?

Diminished participation in significant activities.

Which of the following assessment data would support the disorder of acrophobia?

A client refuses to go to Europe because of fear of flying.

In which situation would the nurse suspect a medical diagnosis of social phobia?

A college student avoids taking classes that include an oral presentation because of

fear of being scrutinized by others.

A client experiencing a panic attack would display which physical symptom?

Sweating and palpitations.

A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive- compulsive disorder. Which behavioral symptom would the nurse expect to assess?

The client uses excessive hand washing to relieve anxiety.

A client with a history of generalized anxiety disorder enters the emergency depart- ment complaining of restlessness, irritability, and exhaustion. Vital signs are blood pressure 140/90 mm Hg, pulse 96, and respirations 20. Based on this assessed information, which assumption would be correct?

A physical examination is needed to determine the etiology of the client’s problem.

Anxiety is a symptom that can result from which of the following physiological condi- tions? Select all that apply.

Chronic obstructive pulmonary disease. Hyperthyroidism.

Hypoglycemia

Which assessment data would support a physician’s diagnosis of an anxiety disorder in a client?

A client experiences increased levels of anxiety that affect functioning in more than

one area of life over a 6-month period.

Which of the following symptom assessments would validate the diagnosis of general- ized anxiety disorder? Select all that apply.

Excessive worry about items difficult to control.
Muscle tension. Feeling “keyed up” or “on edge.”

A client diagnosed with obsessive-compulsive disorder is newly admitted to an in- patient psychiatric unit. Which cognitive symptom would the nurse expect to assess?

Excessive worrying about germs and illness.

A client diagnosed with hypersomnia states, “I can’t even function anymore; I feel worthless.” Which nursing diagnosis would take priority?

Risk for suicide R / T expressions of hopelessness.

A newly admitted client diagnosed with posttraumatic stress disorder is exhibiting recurrent flashbacks, nightmares, sleep deprivation, and isolation from others. Which nursing diagnosis takes priority?

Risk for injury R / T exhaustion because of sustained levels of anxiety.

A client leaving home for the first time in a year arrives on the psychiatric in-patient unit wearing a surgical mask and white gloves and crying, “The germs in here are going to kill me.” Which nursing diagnosis addresses this client’s problem?

Social isolation R / T fear of germs AEB continually refusing to leave the home.

A client seen in an out-patient clinic for ongoing management of panic attacks states, “I have to make myself come to these appointments. It is hard because I don’t know when an attack will occur.” Which nursing diagnosis takes priority?

Social isolation R / T fear of spontaneous panic attacks.

A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive- compulsive disorder. Which correctly stated nursing diagnosis takes priority?

Anxiety R / T obsessive thoughts AEB ritualistic behaviors.

During an assessment, a client diagnosed with generalized anxiety disorder rates anxi- ety as 9/10 and states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority?

Risk for suicide R / T expressing thoughts of suicide.

A client has a nursing diagnosis of disturbed sleep patterns R / T increased anxiety AEB inability to fall asleep. Which short-term outcome is appropriate for this client?

The client will ask for prescribed PRN medication to assist with falling asleep by day 2.

A hospitalized client diagnosed with posttraumatic stress disorder has a nursing diag- nosis of ineffective coping R/T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this client problem?

The client will recognize triggers that precipitate alcohol abuse by day 2.

Which client would the charge nurse assign to an agency nurse who is new to a psychi- atric setting?

A client admitted 4 days ago with the diagnosis of algophobia.

A newly admitted client diagnosed with social phobia has a nursing diagnosis of social isolation R/T fear of ridicule. Which outcome is appropriate for this client?

The client will participate in two group activities by day 4.

When a client experiences a panic attack, which outcome takes priority?

The client will remain safe throughout the duration of the panic attack.

The nurse has received evening report. Which client would the nurse need to assess first?

A client pacing the halls and stating that his anxiety is an 8/10.

A client was admitted to an in-patient psychiatric unit 4 days ago for the treatment of obsessive-compulsive disorder. Which outcome takes priority for this client at this time?

The client will use one relaxation technique to decrease obsessive or compulsive behaviors.

A client diagnosed with generalized anxiety disorder has a nursing diagnosis of panic anxiety R/T altered perceptions. Which of the following short-term outcomes is most appropriate for this client?

The client will be able to intervene before reaching panic levels of anxiety by discharge.

A 10-year-old client diagnosed with nightmare disorder is admitted to an in-patient psychiatric unit. Which of the following interventions would be appropriate for this client’s problem? Select all that apply.

Involving the family in therapy to decrease stress within the family.

Administering medications such as tricyclic antidepressants or low-dose benzodi-azepines or both.

Using relaxation therapy, such as meditation and deep breathing techniques, to assist the client in falling asleep.

A client experiencing sleepwalking is newly admitted to an in-patient psychiatric unit. Which nursing intervention would take priority?

Equip the bed with an alarm that is activated when the bed is exited.

A client on an in-patient psychiatric unit is experiencing a flashback. Which interven- tion takes priority?

Maintain and reassure the client of his or her safety and security.

A client diagnosed with panic attacks is being admitted for the fifth time in 1 year because of hopelessness and helplessness. Which precaution would the nurse plan to implement?

A client diagnosed with obsessive-compulsive disorder has been hospitalized for the last 4 days. Which intervention would be a priority at this time?

Reinforce the use of learned relaxation techniques.

The nurse on the in-patient psychiatric unit should include which of the following interventions when working with a newly admitted client diagnosed with obsessive- compulsive disorder? Select all that apply.

Assess previously used coping mechanisms and their effects on anxiety.

Allow time for the client to complete compulsions.

Discuss client feelings surrounding the obsessions and compulsions.

A client diagnosed with generalized anxiety disorder complains of feeling out of con- trol and states, “I just can’t do this anymore.” Which nursing action takes priority at this time?

Ask the client, “Are you thinking about harming yourself?”

During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, “I’m thinking about suicide.” Which nursing intervention takes priority?

Ask the client, “Do you have a plan to commit suicide?”

A client diagnosed with posttraumatic stress disorder has a nursing diagnosis of dis- turbed sleep patterns R / T nightmares. Which evaluation would indicate that the stat- ed nursing diagnosis was resolved?

The client states that the client feels rested when awakening and denies nightmares.

The nurse teaches an anxious client diagnosed with posttraumatic stress disorder a breathing technique. Which action by the client would indicate that the teaching was successful?

The client maintains a 3/10 anxiety level without medications.

The nurse is using a cognitive intervention to decrease anxiety during a client’s panic attack. Which statement by the client would indicate that the intervention has been successful?

“I reminded myself that the panic attack would end soon, and it helped.”

Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply.

(Catapres).
(Luvox).

(BuSpar).

(Xanax).

Which teaching need is important when a client is newly prescribed buspirone (BuSpar) 5 mg tid?

Encourage the client to take the medication continually as prescribed because onset

of action is delayed 2 to 3 weeks.

Which intervention would the nurse add to the care plan for a client who engages in ritualistic behavior?

Which nursing intervention would be indicated for a client with an anxiety disorder?

Which group therapy intervention is of primary importance to a client with panic disorder?

Which nursing intervention is appropriate for the patient with generalized anxiety disorder GAD )?