Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
A. Sudden unexplained loss of vision
Option a is not a typical finding associated with GAD. Sudden unexplained loss of vision may be a symptom of a neurological or ophthalmologic condition, but not specifically related to GAD.
B. Constant worry about the undiagnosed presence of an illness for more than 6 months
Generalized anxiety disorder (GAD) is a type of anxiety disorder characterized by excessive and persistent worry about a variety of different things, including health, work, relationships, and everyday situations. People with GAD may experience physical symptoms, such as fatigue, muscle tension, and restlessness.
C. Obsession over a fictitious defect in physical appearance
Option c describes a condition called body dysmorphic disorder (BDD), which is a type of obsessive- compulsive disorder characterized by an excessive preoccupation with a perceived physical flaw. BDD is not typically associated with GAD.
D. Prior physical health followed by the need for two surgeries within the last three months
Option d does not describe a typical finding associated with GAD. While physical health issues can contribute to anxiety, the need for surgeries within the last three months is not necessarily indicative of GAD. Therefore, the correct option is b. Constant worry about the undiagnosed presence of an illness for more than 6 months. People with GAD often worry about their health and the possibility of having an undiagnosed illness, even when there is no evidence of a problem. This worry may persist for six months or more and can interfere with daily life.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health - Proctored Exam 2. Take the full exam now
Full Explanation
Generalized anxiety disorder (GAD) is a type of anxiety disorder characterized by excessive and persistent worry about a variety of different things, including health, work, relationships, and everyday situations. People with GAD may experience physical symptoms, such as fatigue, muscle tension, and restlessness.
Option a is not a typical finding associated with GAD. Sudden unexplained loss of vision may be a symptom
of a neurological or ophthalmologic condition, but not specifically related to GAD.
Option c describes a condition called body dysmorphic disorder (BDD), which is a type of obsessive- compulsive disorder characterized by an excessive preoccupation with a perceived physical flaw. BDD is not typically associated with GAD.
Option d does not describe a typical finding associated with GAD. While physical health issues can contribute to anxiety, the need for surgeries within the last three months is not necessarily indicative of GAD.
Therefore, the correct option is b. Constant worry about the undiagnosed presence of an illness for more than 6 months. People with GAD often worry about their health and the possibility of having an undiagnosed illness, even when there is no evidence of a problem. This worry may persist for six months or more and can interfere with daily life.
Similar Questions
A nurse is caring for a client who smokes and has lung cancer. The client reports, “I'm coughing because I have that cold that everyone has been getting.”
The nurse should identify that the client is using which of the following defense mechanisms?
A. Denial
Denial is a defense mechanism where an individual refuses to accept or acknowledge the existence of a problem or a reality that causes anxiety or distress. In this scenario, the client is denying that their coughing is related to their lung cancer, and instead attributing it to a common cold that everyone is getting. This denial may be a way for the client to avoid facing the reality of their illness and the potential consequences of smoking.
B. Reaction formation
Option b, reaction formation, is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings to reduce anxiety.
C. Sublimation
Option c, sublimation, is a defense mechanism where an individual channels their unacceptable impulses into more acceptable or socially appropriate behaviors.
D. Suppression
Option d, suppression, is a defense mechanism where an individual consciously pushes down or avoids their thoughts or feelings. None of these defense mechanisms are being exhibited in the scenario described.
Full Explanation
Denial is a defense mechanism where an individual refuses to accept or acknowledge the existence of a problem or a reality that causes anxiety or distress. In this scenario, the client is denying that their coughing is related to their lung cancer, and instead attributing it to a common cold that everyone is getting. This denial may be a way for the client to avoid facing the reality of their illness and the potential consequences of smoking.
Option b, reaction formation, is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings to reduce anxiety.
Option c, sublimation, is a defense mechanism where an individual channels their unacceptable impulses into more acceptable or socially appropriate behaviors.
Option d, suppression, is a defense mechanism where an individual consciously pushes down or avoids their thoughts or feelings. None of these defense mechanisms are being exhibited in the scenario described.
A 26-month-old child displays many negative behaviors. The parent says, "My child refuses toilet training and shouts, 'No, no, no!' when given directions. What do you think is wrong?" Select the registered nurse's best reply:
Select one:
A. The child needs more control. You have been weak."
Option a. “The child needs more control. You have been weak” is not a helpful response because it places blame on the parent and does not provide any useful information or guidance.
B. Some undesirable attitudes are developing at this time. A child psychologist can help you develop a remedial plan.
Option b. “Some undesirable attitudes are developing currently. A child psychologist can help you develop a remedial plan” may be an appropriate response if the child’s behaviors were significantly outside the norm for their age or if they were causing significant distress or disruption. However, based on the information provided by the parent, this does not appear to be the case.
C. This is normal for your child's age. The child is striving for independence."
The child is striving for independence.” The behaviors described by the parent are typical for a child who is 26 months old. At this age, children are beginning to develop a sense of autonomy and independence, and they may resist direction and assert their own will. Toilet training can also be a challenging process for both children and parents, and it is not uncommon for children to resist or refuse toilet training at first.
D. "There may be developmental problems. Most children are toilet trained by age 2 years and a half.
Option d. “There may be developmental problems. Most children are toilet trained by age 2 years and a half” is not a helpful response because it may cause unnecessary worry or concern for the parent. While many children are toilet trained by age 2 and a half, there is a wide range of normal variation in when children achieve this milestone.
Full Explanation
The child is striving for independence.” The behaviors described by the parent are typical for a child who is 26 months old. At this age, children are beginning to develop a sense of autonomy and independence, and they may resist direction and assert their own will. Toilet training can also be a challenging process for both children and parents, and it is not uncommon for children to resist or refuse toilet training at first.
Option a. “The child needs more control. You have been weak” is not a helpful response because it places blame on the parent and does not provide any useful information or guidance.
Option b. “Some undesirable attitudes are developing currently. A child psychologist can help you develop a remedial plan” may be an appropriate response if the child’s behaviors were significantly outside the norm for their age or if they were causing significant distress or disruption. However, based on the information provided by the parent, this does not appear to be the case.
Option d. “There may be developmental problems. Most children are toilet trained by age 2 years and a half” is not a helpful response because it may cause unnecessary worry or concern for the parent. While many children are toilet trained by age 2 and a half, there is a wide range of normal variation in when children achieve this milestone.
Which assessment finding for a client diagnosed with an eating disorder meets a criterion for
hospitalization? Select one:
A. Pulse rate: 55 beats/min
B. Serum potassium: 3.5 mEq/L
C. Systolic blood pressure: 62 mm Hg
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
D. urine output: 90 ml/3 hr.
Full Explanation
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
