QUESTIONS AND DETAILED CORRECT
ANSWERS | A+ GRADE VERIFIED
ANSWERS
The night nurse is caring for a client with post-traumatic
stress disorder (PTSD) and finds him crying on the floor,
repeatedly saying, "I didn't mean to kill all those people."
After examining the client and assisting him safely back to
bed, which of the following actions should the nurse do
first?
1. Notify the nurse manager
2. File and incident report on the fall
3. Raise all the bed rails up to prevent the client from
falling from his bed again
4. Put the bed alarm back on Correct Answer 4. Put the
bed alarm back on
A client has high levels of anxiety that interfere with their
ability to work, disrupts their relationships and changes
their ability to interact with others. Which nursing diagnosis
stem would be appropriate for this client?
1. Ineffective coping
2. Social isolation
3. Ineffective health maintenance
4. Chronic low self-esteem Correct Answer 1. Ineffective
coping
,A client with severe anxiety is admitted to an inpatient
psychiatry unit. The nursing diagnosis on the care plan
states the client is experiencing ineffective health
maintenance due to severe anxiety. Which of the following
client statements support this diagnosis?
1. "I just feel so hopeless I don't have any control over my
life"
2. "I eat all of the time to try to distract myself from my
anxiety"
3. "I just can't stop making sure the stove is turned off my
routine takes over everything in my life"
4. "I keep having recurring memories about an accident I
had as a child" Correct Answer 3. "I just can't stop making
sure the stove is turned off my routine takes over
everything in my life"
A client with anxiety has an increased heart rate,
respirations, and blood pressure. They are experiencing
moderate discomfort and narrowing of perceptual fields.
Which nursing intervention is most appropriate for this
client?
1. Explore behaviors that have worked to relieve anxiety in
the past
2. Minimize the environmental stimuli and move the client
to a quieter setting
3. Use a low pitched voice and speak slowly
,4. Set physical limits in order to ensure client safety
Correct Answer 1. Explore behaviors that have worked to
relieve anxiety in the past
A client is experiencing pain levels of anxiety. The nurse
moves the client to a quiet space with minimal stimulation.
Which initial nursing action will promote client safety?
1. The nurse remains with the client
2. The nurse uses clear and simple statements when
communicating with the client
3. The nurse offers the client high-calorie fluids
4. The nurse assesses the need for medication and
seclusion Correct Answer 1. The nurse remains with the
client
A client newly diagnosed with moderate anxiety is focused
on feelings of "skipped heartbeats" during anxious states.
How should the nurse respond to the client?
1. "As the adrenaline levels increase in your body it is
common to have feelings of skipped heartbeats or a racing
heart"
2. "This may be a sign of a heart attack you need to
contact your health care provider (HCP)"
3. "It is important for you not to worry about these skipped
beats they will not harm you"
4. "These skipped heartbeats will disappear once your
anxiety is managed" Correct Answer 1. "As the adrenaline
levels increase in your body it is common to have feelings
of skipped heartbeats or a racing heart"
, A client with an anxiety disorder is experiencing ritualistic
behaviors and phobia to germs. The nurse is concerned
these behaviors will impact the client's ability to engage in
self-care practices. What is a priority area for an initial
assessment in this client?
1. To assess their eating practices and fluid intake
2. To assess how much time the client spends on
grooming, bathing and dressing
3. To assess if the client is suppressing the urge to void or
defecate
4. To assess if the client is sleeping regularly Correct
Answer 1. To assess their eating practices and fluid intake
A client with severe anxiety asks the nurse for education
regarding mindfulness. What is the nurse's first step in the
teaching-learning process with this client?
1. Provide links to online mindfulness exercises
2. Demonstrate mindfulness techniques to the client
3. Reinforce the client's health literacy by providing
evidence-informed information on mindfulness
4. Demonstrate active listening and explore the client's
interest in mindfulness in more detail Correct Answer 4.
Demonstrate active listening and explore the client's
interest in mindfulness in more detail
A client is experiencing moderate anxiety due to an
upcoming surgical procedure in 2 hours. How can the
nurse best support the client?