A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility 1 week ago.
A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again.
Client appears to be well-groomed.
Client’s current weight is 54 kg (119 lb).
Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Verbalizes decreased appetite and gastrointestinal discomfort.
Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Verbalizes that bullying experienced during high school has led to anxiety.
Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
Client appears to be well-groomed.
Client’s current weight is 54 kg (119 lb).
Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Verbalizes decreased appetite and gastrointestinal discomfort.
Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Verbalizes that bullying experienced during high school has led to anxiety.
Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
The Correct Answer is ["A","C","G","H"]
Choice A: Client appears to be well-groomed.
Reason: Being well-groomed can indicate that the client is taking care of their personal hygiene and appearance, which is often a sign of improved mental health and self-esteem. This is particularly relevant for clients with anxiety or depression, as neglecting personal care can be a symptom of these conditions.
Choice B: Client’s current weight is 54 kg (119 lb).
Reason: The client’s weight has remained stable since admission (54.4 kg to 54 kg). While this indicates no further weight loss, it does not necessarily indicate an improvement in anxiety symptoms. Weight stability alone is not a direct indicator of mental health improvement.
Choice C: Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Reason: An increase in sleep duration from 3-4 hours to 5-6 hours per night suggests an improvement in the client’s sleep pattern, which is a positive sign in managing anxiety. Occasional nightmares are still present, but the overall increase in sleep is beneficial.
Choice D: Verbalizes decreased appetite and gastrointestinal discomfort.
Reason: Continued decreased appetite and gastrointestinal discomfort indicate ongoing anxiety symptoms. These are not signs of improvement and suggest that the client is still experiencing significant anxiety.
Choice E: Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Reason: This statement reflects ongoing social anxiety and fear of judgment, indicating that the client is still struggling with anxiety symptoms. This is not an indicator of improvement.
Choice F: Verbalizes that bullying experienced during high school has led to anxiety.
Reason: Acknowledging the source of anxiety (bullying) is important for therapy, but it does not directly indicate an improvement in the client’s current anxiety symptoms.
Choice G: Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Reason: Active participation in therapeutic techniques like thought-stopping and cognitive restructuring indicates that the client is engaging in strategies to manage and reduce anxiety. This is a positive sign of improvement.
Choice H: Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
Reason: Consistent medication adherence is crucial for managing anxiety symptoms. The client’s regular intake of escitalopram suggests they are following their treatment plan, which is a positive indicator of improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
The statement "You should take a 2-hour nap during the afternoon" is not advisable. While short naps can be beneficial, long naps, especially those taken late in the day, can interfere with nighttime sleep by reducing sleep drive. It is generally recommended to limit naps to 20-30 minutes and to avoid napping late in the afternoon.
Choice B reason:
The statement "You should relax by watching a television show in bed before going to sleep" is not recommended. Watching television or using other electronic devices before bed can negatively impact sleep quality. The blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. It is better to engage in relaxing activities that do not involve screens, such as reading a book or listening to calming music.
Choice C reason:
The statement "You should avoid stressful activities prior to going to sleep" is the correct response. Engaging in stressful activities before bed can increase anxiety and make it difficult to fall asleep. It is important to establish a relaxing bedtime routine that includes activities such as deep breathing exercises, meditation, or gentle stretching to promote better sleep.
Choice D reason:
The statement "You should plan to exercise 2 hours before going to sleep" is partially correct but not ideal. While regular exercise can improve sleep quality, exercising too close to bedtime can have the opposite effect for some people. It is generally recommended to finish exercising at least 3-4 hours before bedtime to allow the body to wind down.
Correct Answer is B
Explanation
Choice A reason:
The statement "Repeat the dose in 15 minutes if the client is still anxious" is not appropriate. Lorazepam is a benzodiazepine that can cause significant sedation and central nervous system depression. Repeating the dose too soon can increase the risk of severe sedation, respiratory depression, and other adverse effects.
Choice B reason:
The statement "Initiate fall precautions for the client" is the correct response. Lorazepam can cause dizziness, drowsiness, and impaired coordination, increasing the risk of falls, especially in older adults. Implementing fall precautions is essential to ensure the client's safety.
Choice C reason:
The statement "Instruct the client to expect ringing in the ears" is incorrect. Tinnitus (ringing in the ears) is not a common side effect of lorazepam. Common side effects include drowsiness, dizziness, and muscle weakness.
Choice D reason:
The statement "Place the client in restraints for 1 hour" is inappropriate. Restraints should only be used as a last resort when the client poses a danger to themselves or others and when less restrictive measures have failed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today