A nurse is caring for a client who has an anxiety disorder.
Which of the following findings should the nurse recognize as a manifestation of mild anxiety?

Insomnia

Chest pain

C. Irritability

Incoherent speech

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Insomnia is a common symptom of anxiety, but it is not typically seen in mild cases. It is more often associated with moderate to severe anxiety.

When anxiety is mild, individuals may experience difficulty falling asleep or staying asleep, but they are not typically unable to sleep at all.

Other sleep-related symptoms of mild anxiety may include restlessness, nightmares, or early morning awakening.

Choice B rationale:

Chest pain is a serious symptom that can be caused by a variety of medical conditions, including anxiety. However, it is not a common manifestation of mild anxiety.

Chest pain associated with anxiety is typically described as a sharp, stabbing pain or a feeling of tightness in the chest. It may be accompanied by other symptoms such as shortness of breath, palpitations, or sweating.

If a client with anxiety is experiencing chest pain, it is important to rule out other potential causes, such as heart disease or a pulmonary embolism.

Choice D rationale:

Incoherent speech is a sign of severe anxiety or a panic attack. It is not typically seen in mild anxiety.

When a person is experiencing incoherent speech, they may have difficulty speaking in complete sentences or making sense of their thoughts. They may also slur their words or speak in a rapid, disjointed manner.

Choice C rationale:

Irritability is a common manifestation of mild anxiety. It is often characterized by a feeling of being easily annoyed or angered.

Individuals with mild anxiety may also be more impatient, short-tempered, or argumentative than usual.

They may also have a lower tolerance for frustration and stress.

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Correct Answer is B

Explanation

Choice A rationale:

Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.

It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.

Choice B rationale:

Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.

Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.

It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.

Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.

Choice C rationale:

Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.

It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.

However, it would not typically be the most urgent finding requiring immediate intervention.

Choice D rationale:

Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.

It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.

However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.

A. Stating that he wants to be with his peers more than with his parents. B. Telling his parents that he doesn’t want to talk about the attempt. C. Preferring to eat his meals while watching TV. D. Planning to give his CD collection to his girlfriend.

Correct Answer is D

Explanation

Planning to give away prized possessions is a significant warning sign of potential suicide. This behavior often signals that the individual is preparing for death and believes they will no longer need those items. It's a concerning indication that they may have made a decision to end their life and are putting their affairs in order.

Here's a detailed breakdown of why this behavior is so concerning:

Final Arrangements: Giving away cherished belongings suggests a sense of finality and a belief that there's no future to look forward to. It's a way of detaching from material possessions and preparing for a perceived ending.

Loss of Interest: When someone loses interest in activities or items they previously valued, it can reflect a profound loss of hope and a withdrawal from life. This detachment is often a feature of suicidal ideation.

Saying Goodbye: Distributing belongings can serve as a symbolic way of saying goodbye to loved ones without explicitly stating suicidal intentions. It's a nonverbal communication of their plans, often done to avoid intervention or to ease the burden on others after their death.

Lack of Self-Preservation: The act of giving away possessions demonstrates a disregard for one's own future needs and a lack of investment in their continued existence. It suggests a mindset that they won't be around to enjoy those items any longer.

No Hope for Change: This behavior can also signal a belief that their circumstances are hopeless and that suicide is the only viable solution. It reflects a sense of despair and a conviction that things won't improve.

It's crucial to note that not all individuals who contemplate suicide will exhibit this specific behavior. However, it's a serious red flag that should never be ignored. If you witness someone giving away their possessions, it's imperative to take immediate action to assess their safety and seek professional help.

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A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who has an anxiety disorder.
Which of the following findings should the nurse recognize as a manifestation of mild anxiety?