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 B

Explanation

A. "Medication compliance.": While medications can help manage mood instability or co-occurring conditions like depression or anxiety, they are not the primary treatment for borderline personality disorder (BPD). The primary focus should be on addressing immediate safety concerns, including self-harm and suicidal tendencies, which are more urgent.
B. "Awareness of potential for self-harm.": Clients with BPD frequently engage in self-harming behaviors or suicidal gestures due to emotional dysregulation, impulsivity, and intense fear of abandonment. Educating the family about recognizing warning signs, providing emotional support, and ensuring access to crisis intervention resources is critical for reducing risk and promoting safety.
C. "Information about insurance coverage.": While understanding insurance coverage can help in accessing long-term treatment, it is not the most urgent need when addressing the safety of a client newly diagnosed with BPD. Immediate interventions should focus on risk assessment and prevention of harmful behaviors.
D. "Resources for group therapy in the community.": Group therapy, such as dialectical behavior therapy (DBT), can be beneficial for long-term symptom management, but in the early stages of diagnosis, ensuring the family's awareness of self-harm risks and how to intervene in a crisis takes priority over therapy referrals.

A. Tell the client that there is nothing there. B. Ask the client to describe what is being seen. C. Touch the client's arm reassuringly. D. Remove the client from the room.

Correct Answer is B

Explanation

A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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