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: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.
Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.
Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.
Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.
Correct Answer is D
Explanation
Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.
Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.
Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.
Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.
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