A nurse on an inpatient mental health unit is assisting with the care of a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?

Voice tremors

Depersonalization

Shakiness

Poor concentration

Answer and Explanation

The Correct Answer is B

A. Voice tremors are associated with moderate anxiety, where the individual begins to exhibit physical signs of distress but still retains some level of focus. At panic-level anxiety, communication becomes severely impaired, often resulting in unintelligible speech or complete loss of verbal ability.
B. Depersonalization, a dissociative symptom in which individuals feel detached from their own body or reality, is a hallmark of panic-level anxiety. During this state, individuals may experience a sense of unreality, feel as though they are outside their body, or believe that their surroundings are distorted, contributing to a profound sense of fear and disorientation.
C. Shakiness is a physiological response observed in moderate to severe anxiety due to increased autonomic arousal. However, at panic-level anxiety, the body is in a state of extreme crisis, often leading to more severe symptoms such as hyperventilation, loss of motor control, and derealization rather than mere shakiness.
D. Poor concentration is characteristic of moderate to severe anxiety, where cognitive function begins to decline due to excessive worry. However, in panic-level anxiety, cognitive function is severely impaired, and the individual may be unable to process information coherently, often leading to complete disorganization of thought.

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Correct Answer is C

Explanation

A. Exhaustion phase. The exhaustion phase occurs when the body's ability to cope with stress is depleted, leading to physical and psychological impairments such as fatigue, burnout, and increased susceptibility to illness. This phase does not align with maintaining performance over an extended period.
B. Alarm phase. The alarm phase is the initial reaction to stress, activating the sympathetic nervous system and triggering the "fight-or-flight" response. While it provides a short-term boost in alertness and energy, it is not sustainable for weeks to months without impairment.
C. Resistance phase. The resistance phase allows the body to adapt to prolonged stress, maintaining homeostasis and function without significant observable impairment. During this phase, the individual continues to perform duties effectively despite ongoing stress.
D. Adaptive phase. The General Adaptation Syndrome does not include an "adaptive phase." Adaptation occurs within the resistance phase, making this answer incorrect.

A. Lithium toxicity B. Alcohol withdrawal C. Tardive dyskinesia D. Opiate withdrawal

Correct Answer is C

Explanation

A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.

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A nurse on an inpatient mental health unit is assisting with the care of a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following phases of Selye's General Adaptation Syndrome (GAS) reflects a nurse's ability to successfully perform duties during a prolonged period of stress lasting weeks to months without any indication of observable impairment?

Correct Answer is C

Explanation

A nurse in a mental health facility is reinforcing teaching to a newly licensed nurse about how to perform an Abnormal Involuntary Movement Scale (AIMS) test on a client. The charge nurse should identify that the AIMS test is used for which of the following conditions?

Correct Answer is C

Explanation

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