Question

Which reason would the nurse include in a response to a client with rheumatoid arthritis who asks the nurse why it is necessary to inject hydrocortisone into the knee joint?

Answer 1

Correct Answers:

Reduces inflammation

Rationale :

➡️Hydrocortisone is a corticosteroid that exerts potent anti-inflammatory effects within the affected joint.

➡️In rheumatoid arthritis, inflammation of the synovial membrane causes pain, swelling, and decreased joint mobility.

➡️Intra-articular injection helps reduce synovial hyperplasia and immune-mediated tissue damage, improving movement.

➡️This localized therapy minimizes systemic corticosteroid side effects while directly controlling joint inflammation.

➡️Reduction in inflammation alleviates pain and stiffness, promoting comfort and joint function restoration.

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Answer 2

Correct Answers:

Having suicidal ideation
Exhibiting tearfulness
Avoiding previously enjoyed activities and relationships

Rationale :

Having suicidal ideation

🔷 Suicidal thoughts in adolescents reflect core depressive pathology—notably hopelessness, worthlessness, and cognitive distortion, and must always trigger a safety assessment.

🔷 In youth, suicidality may present as direct statements, veiled comments, or risk-taking behaviors, so nurses should use direct, non-judgmental questions (e.g., plan, means, intent).

🔷 High-risk flags include prior attempts, substance use, access to lethal means, family conflict, and bullying, necessitating immediate escalation and possible one-to-one monitoring.

🔷 Best practice includes validated screening (e.g., PHQ-A, C-SSRS) and a collaborative safety plan, with rapid referral to mental health services.

🔷 Early identification and intervention reduce morbidity and mortality, aligning with the nursing priority of preserving life and stabilizing risk.

Exhibiting tearfulness

🔷 Persistent crying or easy tearfulness signals emotional dysregulation and low mood, common in adolescent depression where irritability may replace overt sadness.

🔷 Tearfulness often coexists with sleep/appetite changes, fatigue, and impaired concentration, mapping to DSM-5 depressive symptoms.

🔷 Nurses should assess duration (≥2 weeks) and functional impact (school, home, peers) to differentiate transient stress from major depression.

🔷 Trauma, grief, interpersonal stressors, and academic pressure can amplify tearfulness; screening for co-occurring anxiety is essential.

🔷 Interventions include therapeutic listening, psychoeducation for caregivers, and timely linkage to CBT/interpersonal therapy, which reduce affective lability and improve coping.

Avoiding previously enjoyed activities and relationships

🔷 Loss of interest (anhedonia) is a hallmark symptom—teens disengage from sports, hobbies, and friends, indicating neurovegetative and motivational deficits.

🔷 This withdrawal predicts worse functional outcomes, including declining grades, social isolation, and increased self-harm risk if unaddressed.

🔷 Nursing assessment should document baseline vs. current engagement, noting sharp reductions as clinically significant.

🔷 Treatment plans emphasize behavioral activation (graded re-engagement in rewarding activities) and family involvement to restore routine and reinforcement.

🔷 Monitoring school attendance, peer contact, and activity logs provides objective markers of recovery and helps tailor therapy goals.

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Answer 3

Correct Answers:

Toilet the client more frequently with supervision.

Rationale :

✨Confused and anxious clients often lose awareness of their surroundings and bodily cues, leading to inappropriate elimination behaviors such as voiding in public areas.

✨The nurse’s role is to identify this as a sign of cognitive disorientation, not a behavioral defiance, and respond therapeutically rather than punitively.

✨Frequent toileting with supervision ensures safety, maintains dignity, and reduces the risk of embarrassment or contamination.

✨It also helps the nurse observe patterns of incontinence and provides an opportunity to offer reassurance and emotional support.

✨This approach demonstrates compassionate, person-centered care, which aligns with best practices in psychiatric and geriatric nursing.

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Answer 4

Correct Answers:

Warm and firm without being punitive.

Rationale :

💎Clients with antisocial personality disorder often display manipulative and deceitful behaviors with little regard for others.

💎They respond best to consistent, structured, and respectful interactions.

💎Being warm and firm establishes trust while maintaining clear boundaries—essential to prevent manipulation or testing of limits.

💎A punitive or overly lenient attitude can reinforce maladaptive behaviors or provoke hostility.

💎The nurse should model appropriate behavior, enforce rules calmly, and focus on accountability rather than blame.

💎This therapeutic stance fosters trust, respect, and predictable structure, which improves compliance and stability.

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Answer 5

Correct Answers:

Help the client understand that the behavior is caused by maladaptive coping with increased anxiety.

Rationale :

🔹Ritualistic behaviors are compulsions used to relieve anxiety stemming from obsessive thoughts.

🔹By helping the client understand the link between anxiety and the ritual, the nurse supports insight and facilitates more adaptive coping strategies.

🔹This understanding forms the foundation for cognitive-behavioral interventions, including exposure and response prevention.

🔹The goal is not to eliminate the ritual immediately but to help the client recognize its purpose as a defense mechanism.

🔹Over time, this increases self-awareness and emotional control, promoting long-term therapeutic progress.

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Answer 6

Correct Answers:

Mild

Rationale :

🌿Mild anxiety enhances alertness, focus, and learning because it increases perceptual awareness and motivation.

🌿At this level, the individual can think clearly, process information, and problem-solve effectively.

🌿It is considered beneficial or adaptive anxiety, as it stimulates attention to detail and performance.

🌿The nurse can use this level to teach coping skills or new behaviors since cognitive function remains intact.

🌿In contrast, higher anxiety levels (moderate to panic) impair concentration and interfere with learning.

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Answer 7

Correct Answers:

Assisting the client in developing new coping mechanisms.

Rationale :

🔶Physical symptoms of stress (somatization) often represent the body's way of expressing psychological distress.

🔶The nurse’s goal is to help the client identify stress triggers and replace maladaptive responses with healthy coping strategies.

🔶Teaching relaxation techniques, problem-solving, and assertiveness training can reduce symptom recurrence.

🔶By focusing on coping rather than limiting discussions or avoidance, the nurse addresses the underlying emotional cause.

🔶This promotes long-term adaptation and psychological resilience rather than temporary symptom relief.

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Answer 8

Correct Answers:

Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed.

Rationale :

🔷Clients with obsessive-compulsive disorder (OCD) perform rituals to reduce anxiety and maintain emotional control.

🔷Abruptly stopping or interrupting these rituals may trigger severe anxiety or panic.

🔷Allowing the behavior to continue within predefined limits gives the client a sense of control and gradually reduces ritual dependency.

🔷Involving the client in setting limits encourages collaboration, autonomy, and accountability.

🔷This approach aligns with therapeutic principles of gradual exposure and response prevention, supporting progress toward anxiety reduction.

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Answer 9

Correct Answers:

Has overwhelming feelings of anxiety

Rationale :

💠In OCD, compulsive behaviors are performed to neutralize anxiety from intrusive obsessions.

💠When the ritual is interrupted, the anxiety cannot be relieved, leading to anger, distress, or agitation.

💠The anger is not personal toward the nurse but an expression of heightened internal tension.

💠Recognizing this emotional connection allows the nurse to respond empathetically and supportively rather than confrontationally.

💠Therapeutic interventions should focus on gradual anxiety reduction and building tolerance to distress.

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Answer 10

Correct Answers:

"You're concerned about what other people are thinking about you."

Rationale :

🔸This response reflects the client’s feelings and underlying concerns, encouraging further exploration.

🔸It demonstrates active listening and empathy, core skills in therapeutic communication.

🔸By verbalizing the client’s emotional state, the nurse validates their experience without judgment or reassurance.

🔸This helps the client gain insight into the connection between guilt and anxiety, promoting self-awareness.

🔸It fosters a safe environment where the client feels understood and more willing to discuss feelings openly.

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QLexNursing

1 :
Which reason would the nurse include in a response to a client with rheumatoid arthritis who asks the nurse why it is necessary to inject hydrocortisone into the knee joint?

2 :
Which characteristic is commonly associated with adolescent depression? Select all that apply. One, some, or all responses may be correct.

3 :
Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

4 :
Which consistent approach would the nurse use for a client diagnosed with an antisocial personality disorder?

5 :
Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior?

6 :
Which level of anxiety enhances the client's learning abilities?

7 :
Which nursing intervention would help a client who exhibits physical symptoms when stressed?

8 :
Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?

9 :
Which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with obsessive-compulsive disorder?

10 :
Which response would the nurse make to a client who says, "l feel so guilty. None of this makes any sense. Everyone must really think I'm crazy," after performing a complex ritual?

QLexNursing

1 : Which reason would the nurse include in a response to a client with rheumatoid arthritis who asks the nurse why it is necessary to inject hydrocortisone into the knee joint?

2 : Which characteristic is commonly associated with adolescent depression? Select all that apply. One, some, or all responses may be correct.

3 : Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

4 : Which consistent approach would the nurse use for a client diagnosed with an antisocial personality disorder?

5 : Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior?

6 : Which level of anxiety enhances the client's learning abilities?

7 : Which nursing intervention would help a client who exhibits physical symptoms when stressed?

8 : Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?

9 : Which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with obsessive-compulsive disorder?

10 : Which response would the nurse make to a client who says, "l feel so guilty. None of this makes any sense. Everyone must really think I'm crazy," after performing a complex ritual?

1 :
Which reason would the nurse include in a response to a client with rheumatoid arthritis who asks the nurse why it is necessary to inject hydrocortisone into the knee joint?

2 :
Which characteristic is commonly associated with adolescent depression? Select all that apply. One, some, or all responses may be correct.

3 :
Which action would the nurse take when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

4 :
Which consistent approach would the nurse use for a client diagnosed with an antisocial personality disorder?

5 :
Which intervention would the nurse add to the plan of care for a client who engages in ritualistic behavior?

6 :
Which level of anxiety enhances the client's learning abilities?

7 :
Which nursing intervention would help a client who exhibits physical symptoms when stressed?

8 :
Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?

9 :
Which reason would be likely for a client's anger and acting out when the nurse interrupts the hand-washing ritual of a client with obsessive-compulsive disorder?

10 :
Which response would the nurse make to a client who says, "l feel so guilty. None of this makes any sense. Everyone must really think I'm crazy," after performing a complex ritual?