Which of the following is a priority when caring for a highly anxious patient?

Implement strict limit-setting to control behavior.

Increase environmental stimuli to distract the patient.

Provide support and a therapeutic milieu.

Provide more freedom to promote self-expression.

Answer and Explanation

The Correct Answer is C

Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.

Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.

Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.

Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.

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Correct Answer is A

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.

Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.

Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.

Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.

A. Fecal impaction B. Incisional infection C. Health care-associated Clostridium difficile D. Paralytic ileus

Correct Answer is D

Explanation

Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.

Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.

Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.

Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.

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Which of the following is a priority when caring for a highly anxious patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

Correct Answer is A

Explanation

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

Correct Answer is D

Explanation

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