Obsessive-Compulsive Disorder is an anxiety disorder. Exercise releases emotional energy, limits time for the maladaptive behavior, and directs the client’s attention outward. Initially, nurses should not interfere with performance of the repetitive act, try reasoning the client out of the behavior, or ridicule the behavior. Psychosocial Integrity

Thrill should be present. The client should be taught to check this daily at home. Pulsation is not typically

visible. Percussion gives no information about the patency of a fistula. Blood pressure is not auscultated in a limb

with an AVF. Auscultation of the AVF, for a bruit, is part of an assessment for patency. Physiological Adaptation

The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what’s

happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present.

Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and

might even find performance enhanced. The individual with moderate anxiety grasps less information about the

situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in

panic demonstrates markedly disturbed behavior and might lose touch with reality. Psychosocial Integrity

Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients

should sit up to prevent backflow of acid into the esophagus. Basic Care and Comfort

To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and

slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp

a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present. Basic Care

and Comfort

Acetaminophen is extensively metabolized in the liver. Choices 1, 3, and 4 are incorrect because prolonged

use of acetaminophen might result in an increased risk of renal dysfunction, but a single overdose does not

precipitate life-threatening problems in the respiratory system, renal system, or adrenal glands. Pharmacological

Therapies

Displacement is the transference of anger to another. Anger is displaced on the dog as a convenient object.

Psychosocial Integrity

A contusion is a soft-tissue injury caused by blunt force. It is an injury that does not break the skin, is caused

by a blow and is characterized by swelling, discoloration, and pain. The immediate application of cold might

limit the development of a contusion. A strain is a muscle pull from overuse, overstretching, or excessive stress.

A sprain is caused by a wrenching or twisting motion. A dislocation is a condition in which the articular surfaces

of the bones forming a joint are no longer in anatomic contact. Physiological Adaptation

Drug tolerance is characterized by the ability to ingest a larger dose without adverse effect and decreased

sensitivity to the substance. Substance dependence is a severe condition indicating physical problems and

disruption of the person’s social, family, and work life. The psychological behaviors related to substance use are

termed addiction. Dual diagnosis is the coexistence of substance abuse and psychiatric disorders. Psychosocial

Integrity

Xanax, like other benzodiazepines, can cause withdrawal symptoms that include agitation, insomnia,

hypertension, seizures, and abdominal pain. The drug must be slowly decreased to prevent withdrawal symptoms.

Psychosocial Integrity

A client with cirrhosis is at risk for developing a high ammonia level. Reduction of Risk Potential

The nurse needs to open the airway first when the oxygen saturation drops. The other actions might be

appropriate, but the airway must be patent. Reduction of Risk Potential

The nurse should change the intravenous tubing on total parenteral nutrition solutions every 24 hours, due to

the high risk of bacterial growth. Health Promotion and Maintenance

Secondary prevention targets the reduction of disease prevalence and disease morbidity through early

diagnosis and treatment. Physiological Adaptation

Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional

problems. Choice 1 is incorrect because it is a nursing intervention, not a goal statement. Choice 3 is incorrect

because it is a therapeutic treatment. Choice 4 is incorrect because weight gain is an appropriate goal only if the

client is underweight. Basic Care and Comfort