A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility one week ago.
A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect, click on the finding again.
The client appears to be well-groomed.
The client’s current weight is 54 kg (119 lb.).
The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare.
The client verbalizes a decreased appetite and gastrointestinal discomfort.
The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
The client verbalizes that bullying experienced during high school has led to anxiety.
The client engages in thought-stopping behavioral therapy and cognitive restructuring.
The client reports taking escitalopram 20 mg daily, 2 hours after breakfast.
The client appears to be well-groomed
The client’s current weight is 54 kg (119 lb.)
The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare
The client verbalizes a decreased appetite and gastrointestinal discomfort
The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
The client verbalizes that bullying experienced during high school has led to anxiety
The client engages in thought-stopping behavioral therapy and cognitive restructuring
The client reports taking escitalopram 20 mg daily, 2 hours after breakfast
The Correct Answer is ["A","C","G","H"]
Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.
An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.
Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.
Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.
The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.
Correct Answer is ["1.4"]
Explanation
Step 1 is to identify the required dose, which is 7 mg of haloperidol.
Step 2 is to identify the concentration of the available haloperidol injection, which is 5 mg/mL.
Step 3 is to calculate the volume to be administered using the formula: Volume = Dose ÷ Concentration.
So, let's calculate:
Volume = 7 mg (Dose) ÷ 5 mg/mL (Concentration)
This gives us:
Volume = 1.4 mL
However, we need to round the answer to the nearest tenth and use a leading zero if it applies. So, the final volume to be administered is 1.4 mL. The nurse should administer 1.4 mL of haloperidol injection.
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