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 C

Explanation

Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.

Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.

Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.

Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.

A. Has recurrent thoughts of past trauma. B. Invents words that have no meaning. C. Preoccupation with washing and folding his clothes. D. Avoids interactions with staff and peers.

Correct Answer is B

Explanation

Choice A reason: Recurrent thoughts of past trauma are more indicative of post-traumatic stress disorder rather than schizophrenia.

Choice B reason: Inventing new words or phrases that have no meaning, also known as neologisms, is a common positive symptom of schizophrenia.

Choice C reason: A preoccupation with washing and folding clothes is not specifically indicative of schizophrenia; it could be a sign of obsessive-compulsive disorder.

Choice D reason: While social withdrawal can be a symptom of schizophrenia, it is considered a negative symptom, not a positive one.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

Correct Answer is C

Explanation

A nurse is caring for a client who has positive manifestations of schizophrenia. Which of the following behaviors should the nurse anticipate?

Correct Answer is B

Explanation

The mental status examination takes place during which part of the nursing process?

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

We encourage the patient to cough and deep breathe after surgery to prevent:

The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?

The mental health status examination includes (select all that apply):

People with Narcissistic Personality Disorder display which of the following behaviors? (Select all that apply.)

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?

Michael's parents have always told him that he is not a good student. Michael starts a small business selling things on the internet and devotes all his time and energy to building it, becoming a successful entrepreneur. Michael's situation is an example of: