A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?

It doesn’t appear as though you are feeling anxious.

Tell me what has been happening lately.

I think you should see a therapist.

Do you think your anxiety is worse than everyone else’s?

Answer and Explanation

The Correct Answer is B

Choice A reason:

Saying “It doesn’t appear as though you are feeling anxious” is not an appropriate response. This statement invalidates the client’s feelings and can make them feel misunderstood or dismissed. It is important for the nurse to acknowledge the client’s report of anxiety and provide a supportive environment for them to express their concerns.

Choice B reason:

“Tell me what has been happening lately” is the most appropriate response. This open-ended question encourages the client to share more about their experiences and feelings, which can help the nurse understand the underlying causes of the anxiety. It also shows empathy and a willingness to listen, which are crucial in building a therapeutic relationship.

Choice C reason:

“I think you should see a therapist” might be a helpful suggestion, but it is not the best immediate response. While referring the client to a therapist can be part of the long-term management plan, the nurse should first listen to the client’s concerns and provide immediate support. Suggesting therapy right away might make the client feel like their concerns are being brushed off.

Choice D reason:

“Do you think your anxiety is worse than everyone else’s?” is not a helpful response. This question can come across as judgmental and may make the client feel defensive or invalidated. It is important for the nurse to focus on understanding the client’s individual experience rather than comparing it to others.

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Correct Answer is D

Explanation

Choice A reason: Taking aspirin while on prednisone can increase the risk of gastrointestinal bleeding. Prednisone, a corticosteroid, can cause stomach irritation, and combining it with aspirin, a nonsteroidal anti-inflammatory drug (NSAID), can exacerbate this effect. Therefore, clients should avoid taking aspirin for minor aches and pains while on prednisone.

Choice B reason: A sore throat is not a common side effect of prednisone. Prednisone can suppress the immune system, making clients more susceptible to infections, but it does not typically cause a sore throat within the first week of use. If a client experiences a sore throat, they should contact their healthcare provider as it may indicate an infection.

Choice C reason: Clients on prednisone should avoid live vaccines, such as the flu vaccine, within one week of starting the medication. Prednisone can weaken the immune system, reducing the effectiveness of the vaccine and increasing the risk of developing the illness the vaccine is meant to prevent. It is generally recommended to consult with a healthcare provider before receiving any vaccines while on prednisone.

Choice D reason: Prednisone can cause potassium loss, leading to hypokalemia. Eating more bananas, which are high in potassium, can help counteract this effect and maintain normal potassium levels. Normal potassium levels range from 3.5 to 5.0 mEq/L. Therefore, clients should increase their intake of potassium-rich foods like bananas while taking prednisone.

A. Intention tremors B. Purple striations C. Hirsutism D. Hyperpigmentation

Correct Answer is D

Explanation

Choice A reason: Intention tremors are not typically associated with Addison’s disease. Intention tremors are more commonly seen in conditions affecting the cerebellum, such as multiple sclerosis or cerebellar ataxia.

Choice B reason: Purple striations (striae) are more commonly associated with Cushing’s syndrome, which is characterized by excessive cortisol levels. Addison’s disease, on the other hand, involves insufficient cortisol production.

Choice C reason: Hirsutism refers to excessive hair growth in women in areas where hair is normally minimal or absent. This condition is more commonly associated with polycystic ovary syndrome (PCOS) or other endocrine disorders, not Addison’s disease.

Choice D reason: Hyperpigmentation is a hallmark sign of Addison’s disease. It occurs due to increased production of melanocyte-stimulating hormone (MSH) as a byproduct of elevated adrenocorticotropic hormone (ACTH) levels. This leads to darkening of the skin, especially in areas exposed to friction, such as the elbows, knees, knuckles, and scars.

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A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?

Nursing Test Bank

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