Nursing Elites

1. A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should not be included in the teaching? Select all that apply.

• A. Deep breathing exercises
• B. Progressive muscle relaxation
• C. Mindfulness meditation
• D. Cognitive restructuring

Correct answer: D

Rationale: Deep breathing exercises, progressive muscle relaxation, and mindfulness meditation are commonly used relaxation techniques to manage anxiety. Cognitive restructuring is a cognitive-behavioral technique aimed at changing negative thought patterns and beliefs, not a relaxation technique. It focuses on altering cognitive distortions rather than inducing physical relaxation responses.

2. A woman was abducted and raped at gunpoint by an unknown assailant. When found, she was confused and disoriented. The nurse makes the following observations about the client. She is talking rapidly in disjointed phrases, is unable to concentrate, and is indecisive when asked to make simple decisions. The client's level of anxiety can be assessed as

• A. moderate
• B. severe
• C. mild
• D. nonexistent

Correct answer: B

Rationale: The client's presentation, including rapid and disjointed speech, inability to concentrate, and indecisiveness, are indicative of severe anxiety. These symptoms suggest a high level of distress and impairment in cognitive functioning, which aligns with severe anxiety rather than mild or moderate levels. The traumatic experience of being abducted and raped at gunpoint would likely contribute to such a severe level of anxiety.

3. A healthcare professional is assessing a client who is experiencing severe anxiety. Which of the following symptoms should the healthcare professional expect to observe?

• A. Restlessness
• B. Rapid heart rate
• C. Sweating
• D. Dry mouth

Correct answer: B

Rationale: Rapid heart rate is a characteristic symptom of severe anxiety due to the body's fight-or-flight response being activated. This physiological response leads to an increased heart rate to prepare the body to deal with perceived threats. Healthcare professionals should be vigilant in monitoring and managing this symptom in clients experiencing severe anxiety.

4. Which of the following would be the most appropriate intervention for a patient experiencing severe anxiety?

• A. Encourage the patient to talk about their feelings.
• B. Use a firm, authoritative approach.
• C. Stay with the patient and provide a quiet environment.
• D. Suggest the patient watch TV to distract themselves.

Correct answer: C

Rationale: During a severe anxiety episode, it's crucial to stay with the patient and create a quiet environment. This approach helps reduce anxiety by providing a sense of safety and support. Encouraging the patient to talk about their feelings may not be effective during an acute episode of severe anxiety. Using a firm, authoritative approach can escalate the situation and worsen the anxiety. Suggesting distractions like watching TV may not address the root cause of the anxiety or provide the necessary support.

5. Which client statement should alert a nurse that a client may be responding maladaptively to stress?

• A. I've found that avoiding contact with others helps me cope.
• B. I really enjoy journaling; it's my private time.
• C. I signed up for a yoga class this week.
• D. I made an appointment to meet with a therapist.

Correct answer: A

Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.

Similar Questions