Which of the following is included in the health teachings among clients receiving Valium?:
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Solution
Take the medication after meals.
Antianxiety medications cause G.I. upset so it should be taken after meals.
Options A: This is specific for antidepressant MAOI. Taking tyramine rich food can cause hypertensive crisis.
Option C: Valium causes dependency. In which case, the medication should be gradually withdrawn to prevent the occurrence of convulsion.
Option D: The dose of Valium should not be doubled if the previous dose was not taken. It can intensify the CNS depressant effects.
Which of the following medications will likely be ordered for the client?”
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Solution
Valium
Antianxiety.
Option A: Antidepressant.
Option C: Antipsychotic.
Option D: Antimanic
It would be most helpful for the nurse to deal with a client with severe anxiety by:
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Solution
Give specific instructions using speak in concise statements.
The client has narrowed perceptual field. Lengthy explanations cannot be followed by the client.
Option B: The client will not be able to identify the cause of anxiety.
Options C and D: The client has difficulty concentrating and will not be able to focus.
Anxiety is caused by:
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Solution
a subjectively perceived threat
Anxiety is caused by a subjectively perceived threat.
Option A: Fear is caused by an objective threat.
Option C: A depressed client internalizes hostility.
Option D: Mania is due to masked depression
Situation: A 29-year-old client newly diagnosed with breast cancer is pacing, with rapid speech headache and inability to focus on what the doctor was saying. The nurse assesses the level of anxiety as:
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Solution
Severe
The client’s manifestations indicate severe anxiety. Option A: Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness,
Option A: Mild anxiety is manifested by slight muscle tension, slight fidgeting, alertness, the ability to concentrate and capable of problem-solving.
Option B: Moderate muscle tension, increased vital signs, periodic slow pacing, increased rate of speech and difficulty in concentrating are noted in moderate anxiety.
Option D: Panic level of anxiety is characterized immobilization, incoherence, feeling of being overwhelmed and disorganization
Five months after the incident the client complains of difficulty to concentrate, poor appetite, inability to sleep and guilt. She is likely suffering from:
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Solution
Post traumatic disorder
Post-traumatic stress disorder is characterized by flashback, irritability, difficulty falling asleep and concentrating following an extremely traumatic event. This lasts for more that one month.
Option A: Adjustment disorder is the maladaptive reaction to stressful events characterized by anxiety, depression, and work or social impairments. This occurs within three (3) months after the event.
Option B: Somatoform disorders are anxiety related disorders characterized by the presence of physical symptoms without demonstrable organic basis.
Option C: Generalized anxiety disorder is characterized by chronic, excessive anxiety for at least 6 months
Crisis intervention carried out to the client has this primary goal:
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Solution
Help her return to her pre-rape level of function
The goal of crisis intervention to help the client return to her level of function prior to the crisis.
Options A, B, and C are interventions or strategies to attain the goal
The nurse acts as a patient advocate when she does one of the following:
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Solution
She postpones the physical assessment until the client is calm
The nurse acts as a patient advocate as she protects the client from psychological harm.
Option A: The nurse acts a counselor.
Option B: The nurse acts as a technician.
Option D: This exemplifies the role of a teacher
During the initial care of rape victims, the following are to be considered EXCEPT:
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Solution
Touch the client to show acceptance and empathy
The client finds touch intrusive and therefore should be avoided.
Option A: Privacy is one of the rights of a victim of rape.
Option C: The client is anxious. Accompanying the client in a quiet room ensures safety and offers emotional support.
Option D: Guilt feeling is common among rape victims. They should not be blamed.
Situation: An 18-year-old female is sexually attacked while on her way home from work. She was brought to the hospital by her mother. Rape is an example of which type of crisis:
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Solution
Adventitious
Adventitious crisis is a crisis involving a traumatic event. It is not part of everyday life.
Option A: Situational crisis is from an external source that upset ones psychological equilibrium.
Options C and D. Are the same. They are transitional or developmental periods in life
The client is very hostile toward one of the staff for no apparent reason. The client is manifesting:
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Solution
Transference
Transference is a positive or negative feeling associated with a significant person in the client’s past that are unconsciously assigned to another.
Option A: Splitting is a defense mechanism commonly seen in a client with personality disorder in which the world is perceived as all good or all bad.
Option C: Countertransference is a phenomenon where the nurse shifts feelings assigned to someone in her past to the patient.
Option D: Resistance is the client’s refusal to submit himself to the care of the nurse
The client on Haldol has pill rolling tremors and muscle rigidity. He is likely manifesting:
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Solution
Pseudoparkinsonism
Pseudoparkinsonism is a side effect of antipsychotic drugs characterized by mask-like faces, pill rolling tremors, muscle rigidity.
Option A: Tardive dyskinesia is manifested by lip smacking, wormlike movement of the tongue.
Option C: Akinesia is characterized by a feeling of weakness and muscle fatigue.
Option D.: Dystonia is manifested by torticollis and rolling back of the eyes
The client says “ the FBI is out to get me.” The nurse’s best response is:
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Solution
“I don’t know anything about that. You are afraid of being harmed.”
This presents reality and acknowledges the clients feeling.
Options A and B are not therapeutic responses because these disagree with the client’s false belief and makes the client feel challenged.
Option D unnecessary exploration of the false.
Clients who are suspicious primarily use projection for which purpose:
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Solution
to deal with feelings and thoughts that are not acceptable
Projection is a defense mechanism where one attributes one’s feelings and inadequacies to others to reduce anxiety.
Option A: This is not true in all instances of projection.
Options C and D. This focuses on the self rather than others
Situation: A 42-year-old male client, is admitted to the ward because of bizarre behaviors. He was given a diagnosis of schizophrenia paranoid type. The client should have achieved the developmental task of:
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Solution
Ego integrity vs. despair
The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage.
Option A: Infancy stage (0 – 18 mos.) is concerned with the gratification of oral needs.
Option B: School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills.
Option C: Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.