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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing a client in restraints should be a last resort, as it can be traumatizing and can escalate agitation.
Restraints can also cause physical injury and psychological distress.
They should only be used when there is an immediate risk of harm to the client or others.
Choice B rationale:
Haloperidol is an antipsychotic medication that can be used to calm agitated clients.
However, it should not be the first-line intervention, as it can have significant side effects, including drowsiness, dizziness, and muscle stiffness.
It is important to assess the client's individual needs and risks before administering haloperidol.
Choice C rationale:
Asking a client to talk about their feelings can be helpful in some situations, but it is not appropriate when a client is agitated and yelling.
The client is likely to be too overwhelmed to engage in meaningful conversation.
It is important to first de-escalate the situation and ensure the safety of everyone involved.
Choice D rationale:
Moving the client to a seclusion room with continuous observation is the most appropriate intervention in this situation.
This will provide the client with a safe and quiet space to calm down.
It will also allow staff to monitor the client closely and intervene if necessary.
Continuous observation is essential to ensure the client's safety and to prevent self-harm.
Correct Answer is B
Explanation
Choice A:
While this response is well-intentioned, it may not be the most therapeutic in this situation. It could be perceived as dismissive of the client's feelings and concerns. Clients with schizophrenia often have difficulty trusting others, and this response could reinforce the client's belief that they are being held against their will.
It's important to acknowledge the client's feelings and concerns, rather than simply stating that the healthcare team is there to help.
Choice B:
This response is the most therapeutic because it uses the technique of reflection. Reflection involves echoing back the client's feelings or thoughts, which can help them feel heard and understood. It can also encourage the client to elaborate on their concerns.
By reflecting the client's statement, the nurse validates their feelings and opens the door for further communication.
Choice C:
This response could be perceived as confrontational or challenging, which could further escalate the client's anxiety. It's generally more helpful to start with a more open-ended question or reflection.
Asking "why" questions can sometimes make people feel defensive or put on the spot.
Choice D:
While relaxation techniques can be helpful for some clients, this response is not appropriate in this situation. It minimizes the client's concerns and does not address their underlying feelings of fear and anxiety.
It's important to validate the client's feelings before suggesting coping strategies.
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