A client is unwilling to go out of the house for fear of 'doing something crazy in public.' Because of this, the client remains homebound, except when accompanied outside by a trusted adult. The nurse determines that the client has:

Correct Answer: A

Rationale: Agoraphobia (A) is fear of being in situations where escape or help might be unavailable, often leading to avoidance of public places unless accompanied, as described. Hematophobia (B) is fear of blood, Claustrophobia (C) is fear of enclosed spaces, and Hypochondriasis (D) is fear of illness—none match the client’s specific fear of acting out publicly.

Correct Answer: D

Rationale: In the context of adult behavioral health nursing, understanding the presentation of Generalized Anxiety Disorder (GAD) is crucial. The correct answer, option D - All of the above, is the most appropriate choice because GAD is characterized not only by excessive worrying but also by a range of physical symptoms. Fatigue and trembling are common manifestations of the heightened state of arousal associated with GAD. Muscle tension is another physical symptom often seen in individuals with GAD due to the continuous state of stress and anxiety they experience. Headache and nausea can also accompany GAD, reflecting the impact of chronic worry on the body. Options A, B, and C are incorrect because they do not encompass the full range of physical symptoms typically seen in GAD. While fatigue and trembling, muscle tension, and headache and nausea are indeed common in individuals with GAD, selecting any one of these options would overlook the comprehensive nature of the physical symptomatology associated with this disorder. Educationally, it is essential for nurses specializing in adult behavioral health to recognize the interplay between psychological symptoms like excessive worrying and physical manifestations in disorders such as GAD. By understanding the holistic presentation of GAD, nurses can provide more comprehensive care, including both pharmacological and non-pharmacological interventions to address the complex needs of individuals struggling with this condition.

Correct Answer: C

Rationale: In the field of Adult Behavioral Health Nursing, understanding the historical contributions of influential figures like Florence Nightingale is essential. The correct answer to the question is C) Notes on Nursing. This publication by Florence Nightingale is a seminal work in nursing history, outlining principles of nursing practice and patient care that are still relevant today. Option A) Nursing Sanitation Notes is incorrect because while Nightingale did emphasize sanitation practices, this is not the title of her publication. Option B) Nursing 101 is incorrect as it is a generic title not associated with Nightingale's specific work. Option D) Nursing Notes is also incorrect as it is too vague and does not capture the significance of Nightingale's specific publication. Educationally, knowing the title of Florence Nightingale's publication is important for nursing students to appreciate the foundational principles of nursing care and understand the historical evolution of the profession. It also underscores the importance of evidence-based practice and the impact of influential nursing leaders on the development of nursing as a profession.

Correct Answer: A

Rationale: In the context of adult behavioral health nursing, understanding cultural differences is crucial for providing effective and culturally sensitive care to patients. In this scenario, the correct answer is A) Eye contact, as eye contact norms vary significantly across cultures. In some cultures, prolonged eye contact may be seen as a sign of respect and attentiveness, while in others, it could be considered rude or confrontational. Therefore, nurses must be aware of these differences to avoid unintentionally offending or alienating patients. Regarding the incorrect options: - B) Slang terms: While slang terms may vary between cultures, they are less likely to cause offense compared to misunderstandings related to non-verbal communication like eye contact. - C) Hand gestures: Hand gestures can also vary widely between cultures, but they are generally less likely to cause offense than misinterpretations related to eye contact. - D) Gender references: While gender references can be culturally sensitive topics, the immediate impact on patient-nurse communication and relationships due to differences in gender references is typically less significant than issues related to eye contact. Educationally, this question highlights the importance of cultural competence in nursing practice, emphasizing the need for healthcare professionals to be mindful of non-verbal communication cues that may differ across cultures. By understanding and respecting these differences, nurses can build trust with patients, enhance communication, and deliver more personalized care that meets the diverse needs of individuals from various cultural backgrounds.

Correct Answer: A

Rationale: In an inpatient psychiatric facility, protecting patient rights and confidentiality is of utmost importance. Option A, "I cannot confirm or deny that Ms. Honey was admitted here," is the correct response because it upholds patient confidentiality and follows the principle of not disclosing any information about a patient without their explicit permission. Option B, "Ms. Honey is in group therapy at present," violates patient confidentiality by revealing Ms. Honey's location and potentially her participation in therapy. Option C, "Hold on, I’ll go see if she is in her room," also breaches confidentiality by confirming or denying Ms. Honey's presence in the facility. Option D, "Are you a family member? Ms. Honey can only receive calls from family members," is discriminatory and does not protect the patient's right to privacy as it limits who can contact the patient. Educationally, this question highlights the ethical and legal responsibilities of nurses in protecting patient confidentiality, especially in sensitive settings like psychiatric facilities. Nurses must understand and adhere to the laws and regulations that govern patient privacy to provide safe and ethical care.