A patient reports, 'I am overwhelmed by stress.' Which question by the nurse would be most important to use in the initial assessment of this patient?

Questions 103

ATI RN

ATI RN Test Bank

Behavioral Nursing Questions Questions

Question 1 of 5

A patient reports, 'I am overwhelmed by stress.' Which question by the nurse would be most important to use in the initial assessment of this patient?

Correct Answer: C

Rationale: The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether or not his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses, such as drinking) and would help the nurse understand how he copes and how well his coping strategies and resources serve him. Of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

Question 2 of 5

A student says, 'Before taking a test, I feel very alert and a little restless.' The nurse can correctly assess the student's experience as

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem?

Correct Answer: C

Rationale: Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

Question 5 of 5

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD?

Correct Answer: C

Rationale: Avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions