The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patient's increasing anxiety level
Which patient behavior is likely an early indication of escalating anxiety?
a. Talking rapidly
b. Pacing around the unit
c. Staring out the window
d. Refusing to go to therapy
ANS: B
Recognize the patient's use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients.
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Which comment made by a client in her first trimester indicates ambivalent feelings?
a. "My body is changing so quickly." b. "I haven't felt well since this pregnancy began." c. "I'm concerned about the amount of weight I've gained." d. "I wanted to become pregnant, but I'm scared about being a mother."
The nurse removes the client's indwelling urinary catheter but, 8 hours later, the client has not voided. Which intervention should the nurse try first to facilitate client voiding?
1. Run a trickle of water in the bathroom. 2. Apply rolling motion over the bladder. 3. Ask about voiding difficulties in the past. 4. Instruct client to run warm water on perineum.
The nurse is taking a history from a Chinese American client who believes in "cold and hot" groups in relation to the cause and the treatment of illness. An example of a "cold" condition would be:
A. Fever. B. Hypertension. C. Leukemia. D. Stomach ulcer.
Which of the following is the single most important technique to prevent and control the transmission of infections?
a. Hand hygiene b. The use of disposable gloves c. Isolation precautions d. Sterilization of equipment