Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?

"Relax. Take a few deep breaths. I'll stay with you."

"I'll take your vital signs and call my supervisor."

"Don't worry. She's done this many times before."

"Why do you think you're having a heart attack, Mr. L?"

Answer and Explanation

The Correct Answer is A

Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.

Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.

Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.

Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.

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Correct Answer is D

Explanation

Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.

Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.

Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.

Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.

A. Decreasing anxiety to a tolerable level. B. Focusing attention on useful tasks. C. Limiting the amount of time available for interaction with others. D. Manipulating and controlling others' behavior.

Correct Answer is A

Explanation

Choice A reason: Clients with OCD often engage in compulsive behaviors, such as cleaning, to manage their anxiety levels. Recognizing this can help the nurse provide appropriate support and interventions.

Choice B reason: While the tasks may seem useful, the compulsive nature of the behavior is driven by anxiety rather than a focus on productivity.

Choice C reason: The behavior is not about limiting social interaction; it is a manifestation of the client's OCD.

Choice D reason: The behavior is not intended to manipulate or control others but is a symptom of the client's OCD.

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Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?

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Naxlex Comprehensive Predictor Exams

Which component of the Mental Health Status Examination focuses on the way a person experiences reality?

Correct Answer is D

Explanation

A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

Correct Answer is A

Explanation

Nurses understand that patients who deliberately pretend to be ill are:

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?

A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

The nurse is assisting in the care of a preoperative patient who states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

The most current thinking on the cause of schizophrenia is that it is:

The nurse is preparing to teach about the long-term complications for patients diagnosed with diabetes. Which finding is accurate?

The nurse is assisting in the care of a preoperative patient. The patient states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?