A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

Generalized anxiety disorder and a nursing diagnosis of fear

Panic disorder and a nursing diagnosis of panic anxiety

Pain disorder and a nursing diagnosis of altered role performance

Altered sensory perception and a nursing diagnosis of panic disorder

Answer and Explanation

The Correct Answer is B

A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.

B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.

C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.

D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.

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Correct Answer is A

Explanation

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

A. This therapy will increase the clients motivation to gain weight B. This therapy will provide the client with control over behavioral choices C. This therapy will reward the client for perfectionist achievement D. This therapy will protect the client from parental overindulgence

Correct Answer is B

Explanation

A. "This therapy will increase the client's motivation to gain weight": Behavior modification focuses on changing specific behaviors through reinforcement or consequences. While motivation may be a component, the primary goal of behavior modification is to address and modify specific behaviors, such as eating habits, rather than solely relying on motivation.

B. "This therapy will provide the client with control over behavioral choices": Anorexia nervosa often involves issues of control, and behavior modification can empower the individual to regain control over their eating behaviors in a structured and supportive manner. It involves setting goals, reinforcing positive behaviors, and providing a sense of control within the therapeutic framework.

C. "This therapy will reward the client for perfectionist achievement": While anorexia nervosa is associated with perfectionism, rewarding for perfectionist achievement may inadvertently reinforce unhealthy behaviors. Behavior modification aims to promote positive behaviors related to health and well-being rather than reinforcing perfectionism.

D. "This therapy will protect the client from parental overindulgence": Behavior modification is not primarily focused on protecting the client from external factors like parental overindulgence. Instead, it aims to modify specific behaviors through positive reinforcement or consequences.

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A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Correct Answer is A

Explanation

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice?

Correct Answer is B

Explanation

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

Which hallucination necessitates the nurse to implement safety measures? The patient says.

A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week?

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?

A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?