Nursing Elites

1. 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.

2. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?

• A. You shouldn't worry about that. It's not real.
• B. I don't see any FBI agents, but it sounds like you're feeling frightened.
• C. Let's talk about something else to take your mind off of it.
• D. Why do you think the FBI is watching you?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

3. A healthcare professional is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety?

• A. Diagnostic blood tests
• B. Awareness of factors creating stress
• C. Relaxation exercises
• D. Identifying support systems

Correct answer: B

Rationale: The correct answer is B: Awareness of factors creating stress. In managing anxiety, the first crucial step is recognizing and being aware of the factors that contribute to stress. Without this awareness, it becomes challenging to effectively address and manage anxiety. Diagnostic blood tests are not typically the initial step in managing anxiety; they may be used to rule out other medical conditions but are not the primary focus. While relaxation exercises can be helpful in managing anxiety, understanding the root causes of stress takes precedence. Identifying support systems is important but comes after recognizing the stress factors to develop a comprehensive management plan.

4. A patient with major depressive disorder is started on a tricyclic antidepressant (TCA). Which common side effect should the nurse educate the patient about?

• A. Hypertension
• B. Diarrhea
• C. Dry mouth
• D. Weight loss

Correct answer: C

Rationale: The correct answer is C: Dry mouth. Dry mouth is a common side effect associated with tricyclic antidepressants (TCAs). TCAs block acetylcholine receptors, leading to anticholinergic effects such as dry mouth, constipation, blurred vision, and urinary retention. It is important for the nurse to educate the patient about this side effect to promote awareness and provide appropriate management strategies, such as maintaining good oral hygiene and staying hydrated. Choice A, hypertension, is not a common side effect of TCAs. Choice B, diarrhea, is not a typical side effect of TCAs; in fact, TCAs are more likely to cause constipation. Choice D, weight loss, is less common with TCAs as they are more likely to cause weight gain.

5. A client with generalized anxiety disorder (GAD) is being discharged. Which of the following instructions should the nurse not include in the discharge teaching?

• A. Practice relaxation techniques daily
• B. Avoid caffeine and alcohol
• C. Engage in regular physical activity
• D. Use benzodiazepines as the first-line treatment

Correct answer: D

Rationale: Discharge instructions for a client with GAD should include practicing relaxation techniques daily, avoiding caffeine and alcohol, engaging in regular physical activity, and seeking support from friends and family. Benzodiazepines are not recommended as the first-line treatment due to their potential for dependence and should not be included in the discharge teaching.

Similar Questions