The psychiatric home care nurse visits a client who tells the nurse that he experiences palpitations,
difficulty breathing, and a sense of overwhelming dread whenever he leaves his home. This problem
began after he was robbed on his way to work.
He has been unable to go to his office for more than a
month. The nurse recognizes this problem as
a. mysophobia.
b. claustrophobia.
c. acrophobia.
d. agoraphobia.
ANS: D
Agoraphobia refers to the client's fear of open spaces. Option A: Mysophobia refers to fear of dirt or
germs. Option B: Claustrophobia refers to fear of closed spaces. Option C: Acrophobia refers to fear
of heights.
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The nursing student is giving a bath to a client on the first clinical day. The physician arrives and removes a wound dressing, and tells the student to redress the wound. Which of the following actions should the student take?
1. Tell the doctor that wound dressings have not been covered in class yet. 2. Cover the wound with gauze. 3. Perform the dressing change. 4. Seek assistance from the instructor or nurse assigned to the client.
For the first hour following delivery, how often should the nurse assess the mother?
a. Every 5 minutes b. Every 10 minutes c. Every 15 minutes d. Every 30 minutes
A patient has an irregularly shaped, brown to black lesion on the upper arm that has changed color recently. The widest diameter is 6 mm. You should:
A. Measure and record the dimensions and schedule follow-up to repeat measurement in 2 weeks B. Biopsy the lesion C. Obtain skin scraping for dermatophytes D. All of the above
A patient with an autoimmune disorder tells the nurse, "My family keeps telling me I don't look sick." Which problem should the nurse use to guide this patient's care?
1. lack of family comprehension about the disease process 2. alteration in body functions 3. inability of the patient to cope with the health problem 4. inability of the patient to tolerate activity