A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following comorbidities should the nurse anticipate when reviewing the client's medical record?

Correct Answer: A

Rationale: In the context of assessing health behavior in nursing, understanding the comorbidities associated with specific mental health disorders is crucial for providing effective care. In the case of obsessive-compulsive disorder (OCD), comorbidities often include conditions that share similar underlying mechanisms or risk factors. The correct answer is A) Anorexia nervosa. This is because OCD and anorexia nervosa frequently co-occur due to their shared characteristics of perfectionism, rigid thinking, and compulsive behaviors. Individuals with OCD may develop anorexia nervosa as a way to exert control over their environment or body in a similar compulsive manner. Option B) Post-traumatic stress disorder (PTSD) is less likely to be a comorbidity with OCD, as the two disorders have distinct etiologies and symptom profiles. While individuals with PTSD may experience intrusive thoughts or compulsive behaviors, these are typically related to trauma exposure rather than the characteristic obsessions and compulsions of OCD. Option C) Agoraphobia and Option D) Delusional disorder are also less likely comorbidities with OCD. Agoraphobia is commonly associated with panic disorder rather than OCD, and delusional disorder involves fixed false beliefs that are not a core feature of OCD. Educationally, this question highlights the importance of recognizing common comorbidities in mental health disorders to provide holistic and individualized care to clients. Understanding these relationships can inform assessment, intervention, and interdisciplinary collaboration in nursing practice.

Correct Answer: A

Rationale: In the context of Selye's General Adaptation Syndrome (GAS), the correct answer to the question is option A) Resistance phase. This phase reflects the body's ability to adapt to the stressor and maintain a heightened state of resistance over a prolonged period of time without apparent impairment. During the Resistance phase, the body continues to cope with the stressor, and physiological functions stabilize at a new, higher level of functioning. In the case of a nurse facing prolonged stress, such as heavy workload or emotionally taxing situations over weeks to months, being in the Resistance phase is crucial for maintaining performance without observable impairment. Option B) Exhaustion phase is incorrect because this phase occurs when the body's resources are depleted after prolonged exposure to stress, leading to a breakdown in adaptation and increased vulnerability to illness or impairment. Option C) Adaptive phase is not a recognized phase in Selye's GAS model. While adaptation is a key component of the stress response, it is not a specific phase in this context. Option D) Alarm phase is the initial phase of GAS where the body first recognizes and responds to a stressor. It is characterized by the activation of the fight-or-flight response, which is not sustainable over prolonged periods without negative consequences. Understanding Selye's GAS model is essential for healthcare professionals like nurses, as it provides insights into how the body responds to stress and the importance of adaptation in maintaining health and performance. Knowing the different phases helps nurses recognize where they, or their patients, may be in the stress response cycle and implement appropriate interventions to promote adaptation and resilience.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Secondary data. Secondary data is information obtained from sources other than the client themselves, such as family members or medical records. In this case, the information provided by the client's family is considered secondary data because it is coming from a source external to the client. Option B) Objective data refers to measurable and observable data obtained through physical assessments or tests. In this case, information provided by the client's family is not objective data as it is based on their perceptions and experiences, rather than concrete measurements. Option C) Subjective data is information based on the client's feelings, perceptions, and experiences. While the family's information may contain subjective elements, the term "subjective" typically refers to data provided directly by the client themselves during assessments. Option D) Historical data refers to past information about the client's health status, treatments, and outcomes. While the information from the client's family may include historical elements, the term "historical" typically refers to data collected from the client's medical records or previous healthcare encounters. Understanding the difference between these types of data is crucial for nurses in assessing and providing care for clients. By recognizing that the information from the client's family is secondary data, the nurse can appropriately integrate it into the client's care plan while being mindful of its source and potential limitations.

Correct Answer: C

Rationale: The correct answer is C) The client adapts well to change. When a client verbalizes the use of coping mechanisms during stress, it indicates that they have developed healthy strategies to manage challenging situations. Coping mechanisms help individuals navigate stressors effectively, leading to better adaptability to changes in their environment or health status. Option A) The client prefers solitary activities to group activities is incorrect because coping mechanisms do not necessarily indicate a preference for solitude. It simply means the client has strategies to manage stress. Option B) The client follows all rules is incorrect as it does not directly relate to the use of coping mechanisms. Following rules may be a behavior unrelated to stress management. Option D) The client prefers to sit quietly is incorrect as it assumes a specific behavior that may not be indicative of how the client copes with stress. Educationally, this question highlights the importance of recognizing and understanding coping mechanisms in nursing practice. It emphasizes the significance of assessing clients' abilities to manage stress and adapt to changes, which are essential skills for providing holistic and effective care. Nurses need to be aware of clients' coping strategies to support their overall well-being and resilience.

Correct Answer: B

Rationale: In this scenario, option B, "I don't want to think or talk about what happened with anyone," indicates the client is experiencing avoidance symptoms. This response aligns with the avoidance symptom criteria of Post-Traumatic Stress Disorder (PTSD), where individuals actively avoid thoughts, feelings, or conversations associated with the traumatic event. Option A, "I just cannot remember anything about the accident," reflects dissociation, not avoidance. Option C, "I am just so sad. I cannot believe that my partner is gone," demonstrates grief and sadness, not avoidance. Option D, "If I wasn't such a bad person, this never would have happened," suggests guilt, not avoidance. In an educational context, understanding these distinctions is crucial for nurses in assessing and providing holistic care for clients recovering from traumatic events. Recognizing avoidance symptoms can guide appropriate interventions and support clients in processing their experiences effectively. It also underscores the importance of assessing mental health alongside physical recovery in nursing practice.