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 D

Explanation

Choice A rationale:
While it's important for the client to be aware of the signs and symptoms of their illness, medication monitoring is a more immediate concern.
Choice B rationale:
Participating in therapy can be beneficial, but it's not the most critical information to provide in this context.
Choice C rationale:
Living away from home is possible for many individuals with bipolar disorder, but medication management is a higher priority.
Choice D rationale:
Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity in individuals taking lithium carbonate for bipolar disorder.

A. Explore changes in life that have occurred after the loss. B. Suggest the need for a psychiatric consultation. C. Offer a referral to pastoral counseling. D. Encourage attending a local support group.

Correct Answer is A

Explanation

Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.

Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.

Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.

Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.

View Question and Answer

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is A

Explanation

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

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?

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?

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

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 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?