A nurse is reviewing the medical record for a client who has generalized anxiety disorder. Which of the following manifestations should the nurse expect to see included in the client's medical record?
The client is preoccupied with a supposed body defect.
The client compulsively bites fingernails.
The client exhibits hoarding behaviors.
The client puts off making decisions.
The Correct Answer is D
A. "The client is preoccupied with a supposed body defect.": This manifestation is more characteristic of body dysmorphic disorder rather than generalized anxiety disorder (GAD).
B. "The client compulsively bites fingernails.": Nail-biting is often associated with obsessive-compulsive disorder (OCD) or other stress-related behaviors rather than GAD.
C. "The client exhibits hoarding behaviors.": Hoarding is typically associated with obsessive-compulsive disorder (OCD) and not generalized anxiety disorder.
D. "The client puts off making decisions.": Individuals with generalized anxiety disorder often experience indecisiveness and procrastination due to excessive worry and fear of making the wrong choice. This is a common manifestation of GAD
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Place the client on his right side if tube resistance occurs: Positioning the client on the right side can help facilitate gastric emptying, but it is not a primary action to ensure NG tube patency. If tube resistance occurs, the nurse should assess and address the resistance more directly.
B) Check the tube patency every 4 hr: Regularly checking the tube patency ensures that the NG tube remains open and functional, preventing blockages and ensuring continuous decompression or feeding as required.
C) Flush the tube with 50 mL of 0.9% sodium chloride irrigation every 8 hr: Flushing the tube helps maintain patency, but the amount and frequency may vary based on facility protocols. Flushing every 8 hours might not be frequent enough to prevent blockages.
D) Maintain the client in a supine position: Keeping the client in a supine position is not recommended for maintaining NG tube patency and may increase the risk of aspiration. A semi-Fowler's position is usually preferred to promote drainage and reduce aspiration risk.
Correct Answer is D
Explanation
A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.
B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.
C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.
D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.
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