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Questions 158

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Question 1 of 5

A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:

Correct Answer: C

Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.

Question 2 of 5

When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

Correct Answer: A

Rationale: Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia, and warm, dry skin. In hypovolemic shock, the client is hypotensive, tachycardiac, with cool skin and delayed capillary refill (>5 seconds).

Question 3 of 5

The client is prescribed levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include?

Correct Answer: B

Rationale: Levothyroxine can cause cardiac side effects like palpitations or chest pain, which should be reported. It is taken in the morning, fiber is not directly related, and food reduces absorption.

Question 4 of 5

A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:

Correct Answer: B

Rationale: The left occipital posterior position presents a larger fetal head diameter, increasing pressure on sacral nerves and prolonging the first stage of labor due to slower fetal descent.

Question 5 of 5

A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?

Correct Answer: D

Rationale: Asking the client to provide an explanation for her feelings is often intimidating. This response is probing and may make the client feel used and valued only for the information she can provide. This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. The emphasis is on working with the client. It shows that there is hope for change through collaboration.

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