Question 1

Which assessment findings indicate to the nurse that a client is experiencing stress? Select all that apply.

Accepted Answer

A)   Chewing on a finger nail
B)   Checking cellular phone
C)   Reading a magazine
D)   Talking with others
E)   Tapping foot A,E

Question 2

The nurse is providing care to a client who is diagnosed with obsessive-compulsive disorder.Which nursing intervention is most appropriate when providing care to this client?

Accepted Answer

A)   Confront the client and ask what purpose the behavior serves.
B)   Tell the client that the behavior is unacceptable and must end.
C)   Interrupt the ritualistic behavior when observed.
D)   Discuss the need to incorporate the behavior with other hospital routines. D

Question 3

Which nursing intervention minimizes the stress and anxiety of hospitalization for a client?

Accepted Answer

A)   Explain all procedures in detail before performing them.
B)   Control the environment of healing.
C)   Demonstrate staff competence by using multiple nurses for care.
D)   Let the client make the majority of decisions about the plan of care. B

Question 4

A nurse is providing discharge instructions to a client recently diagnosed with obsessive-compulsive disorder (OCD)and prescribed Fluvoxamine (Luvox).Which statement made by the client indicates to the nurse that the client understands the instructions?

Accepted Answer

A)   "I am glad the physician chose this medication because it does not have any side effects."
B)   "I should continue taking this medication and in 1-2 years I can stop taking it."
C)   "I should continue taking this medication and in 1-2 years my physician may taper me off gradually."
D)   "Even though I don't think this medication is for my OCD I will take it because the physician wants me to."

Question 5

The home care nurse observes a client scrubbing areas throughout the house over and over,especially areas where the family gathers.Prior to planning care for this client,which must the nurse assess?

Accepted Answer

A)   If the client is forgetful
B)   If the client vomits during cleaning
C)   How frequently the client cleans the house
D)   The impact of symptoms on the family system

Question 6

After a mammogram,a client is told that she needs a fine needle aspirate of a breast mass.Which actions by the client demonstrates engagement in a primary appraisal of the stressful situation?

Accepted Answer

A)   Holding her breath while the nurse is talking
B)   Sitting in the dressing room and cries
C)   Asking the nurse if she has cancer
D)   Scheduling the procedure in 6 weeks, which is the earliest possible appointment

Question 7

The nurse is reviewing the effectiveness of care provided to a client diagnosed with posttraumatic stress disorder.Which outcomes would indicate the interventions in the plan of care have been effective? Select all that apply.

Accepted Answer

A)   The client takes a sedative at least 4 times a day.
B)   The client has been sleeping throughout the night.
C)   The client keeps all of the lights on at home.
D)   The client verbalizes future plans with family and friends.
E)   The client will not enter a car with fewer than three people.

Question 8

After an assessment,the nurse determines that an older adolescent client is experiencing a maturational crisis because of which findings? Select all that apply.

Accepted Answer

A)   Relationship with significant other ended
B)   Inability to focus on school studies
C)   Cannot sleep at night and skips classes
D)   Recent death of a friend
E)   Graduating from high school in 2 months

Question 9

A client asks for a hospital bed near the door because of a fear of being trapped in a room and not being able to get out.When planning care for this client,which does the nurse include as a possible cause for this client's fear?

Accepted Answer

A)   Genetic predisposition
B)   A traumatic event
C)   Observing others
D)   Informational transmission

Question 10

Which nursing diagnosis would be appropriate for a client with a fear of doctors and hospitals?

Accepted Answer

A)   Ineffective Health Maintenance
B)   Depression
C)   Anxiety
D)   Ineffective Coping

Question 11

The nurse is caring for a client who was diagnosed with posttraumatic stress disorder 4 months ago.Which should the nurse include in the client's plan of care?

Accepted Answer

A)   Guidelines on conducting activities of daily living
B)   Information on the treatments available
C)   Referral to local employment agency
D)   Information on the need for adequate exercise

Question 12

A client,who was recently being laid off from work,is scheduled for a biopsy to detect a malignancy.When planning this client's care,which does the nurse include?

Accepted Answer

A)   Reasons to delay the biopsy
B)   Medicate around the clock for pain
C)   Interventions to address anxiety
D)   Social services to aid with financial planning

Question 13

A nurse on the behavioral health unit is caring for a client diagnosed with depression,who just lost a spouse in a motor-vehicle accident.The client states to the nurse,"my wife would not have wanted to live if she were disabled." Based on this statement,which defense mechanism is the client using?

Accepted Answer

A)   Identification
B)   Denial
C)   Intellectualization
D)   Displacement

Question 14

The nurse is discharging a client diagnosed with general anxiety disorder (GAD).The client is prescribed a selective serotonin reuptake inhibitor (SSRI).Which statement made by the client would indicate to the nurse a need for further education?

Accepted Answer

A)   "This medicine could make me feel like I have the jitters."
B)   "I may experience some nausea while on this medication."
C)   "My doctor will start me off on a high dose and then decrease the dose."
D)   "This medicine alters the levels of the neurotransmitter serotonin in the brain."

Question 15

A client is experiencing severe anxiety associated with a phobia.Which nursing actions are appropriate when providing care to the client? Select all that apply.

Accepted Answer

A)   Explain why the reaction to the phobia is unrealistic.
B)   Make sure the client understands that she is safe.
C)   Teach why the phobia is imagined.
D)   Coach the client to deep breathe.
E)   Ensure a quiet and calm environment.

Question 16

When caring for a client newly diagnosed with obsessive-compulsive disorder,which action by the nurse is appropriate?

Accepted Answer

A)   Do not interrupt the ritual.
B)   Interrupt the ritual.
C)   Teach about antianxiety foods.
D)   Teach ritual interruption skills.

Question 17

The nurse is concerned that a client is demonstrating signs of obsessive-compulsive disorder.Which clinical manifestations observed during the nursing assessment causes the nurse to come to this conclusion? Select all that apply.

Accepted Answer

A)   Not making eye contact with the nurse
B)   Female age 25
C)   Client checking the contents of a purse several times within minutes
D)   Client repeating the words "third floor"
E)   Client asking to use the bathroom in the middle of the assessment

Question 18

A clinic nurse is assessing a client who is experiencing crisis.The nurse needs to determine the client's immediate needs.Which is the priority action by the nurse?

Accepted Answer

A)   Scan for physical distress.
B)   Explore perceptions of the crisis.
C)   Develop a follow-up plan.
D)   Assess for immediate safety needs.

Question 19

During the assessment,the nurse observes a client who was a victim of a home invasion abruptly stand up and begin to run out of the room in response to hearing a loud bang.Which should the nurse assume regarding the client's behavior?

Accepted Answer

A)   The client thought there was an earthquake.
B)   The client was reacting to the loud noise as a form of a flashback.
C)   The client wanted to check the cause for the loud noise.
D)   The client thought the assessment was concluded.

Question 20

Which instruction by the nurse to a client prescribed diazepam (Valium)for anxiety and stress is appropriate?

Accepted Answer

A)   "This medication will be good to take for a long time."
B)   "Take this medication every time feelings of stress become overwhelming."
C)   "This medication works best if taken with a meal."
D)   "This medication is good to use for the short term only."

Exam 31: Stress and Coping