Exhibits

For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.

"This diagnosis means that I am crazy."

"I can learn to manage my thoughts better through therapy."

"I can use holistic approaches like meditation to help my symptoms."

"Many people have the same response to a stressful situation as I am having right”

"I am at high risk for post-traumatic-stress disorder because I have acute stress disorder”

"I will probably need to be on medication for the rest of my life."

"This diagnosis means that I am crazy."

"I can learn to manage my thoughts better through therapy."

"I can use holistic approaches like meditation to help my symptoms."

"Many people have the same response to a stressful situation as I am having right”

"I am at high risk for post-traumatic-stress disorder because I have acute stress disorder”

"I will probably need to be on medication for the rest of my life."

Answer and Explanation

The Correct Answer is ["A","C","D","F"]

Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."

Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.

Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.

Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.

Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD

Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Choice A rationale:
This statement expresses the client's emotional state but does not provide information about immediate access to lethal means.

Choice B rationale:
This comment is the most crucial to document because it indicates the client's access to potentially lethal means, which is a significant risk factor for committing suicide.

Choice C rationale:
This statement provides information about a source of support in the client's life but does not indicate immediate access to lethal methods.

Choice D rationale:
This statement provides information about the frequency of panic attacks but does not indicate immediate access to lethal means.

A. Applies prescribed lotions to the radiation site. B. Washes the radiation site with antibacterial soap and water. C. Wears clothing to cover the radiation site. D. Dries the area with patting motions after taking a shower.

Correct Answer is B

Explanation

Choice A rationale:
Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation.

Choice B rationale:
Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gentle, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area. Antibacterial soap may be too harsh and could lead to skin irritation.

Choice C rationale:
Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritation.

Choice D rationale:
Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Correct Answer is B

Explanation

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Correct Answer is B

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?