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 D
Explanation
Choice A reason:
The statement "Rapid mood swings" is not typically associated with Alzheimer's disease. While mood changes can occur, they are usually more gradual and related to frustration or confusion rather than rapid swings. Alzheimer's disease primarily affects memory and cognitive functions, leading to progressive decline in these areas.
Choice B reason:
The statement "Excessive motor activity" is not a common finding in Alzheimer's disease. Patients with Alzheimer's may experience restlessness or wandering, but excessive motor activity is more characteristic of other conditions such as mania or certain types of dementia.
Choice C reason:
The statement "Altered level of consciousness" is not a typical symptom of Alzheimer's disease. Alzheimer's patients usually maintain a normal level of consciousness until the later stages of the disease, where severe cognitive decline can lead to reduced awareness. Altered level of consciousness is more commonly associated with acute conditions such as delirium or other neurological disorders.
Choice D reason:
The statement "Failure to recognize familiar objects" is the correct response. This symptom, known as agnosia, is a hallmark of Alzheimer's disease. As the disease progresses, patients often lose the ability to recognize familiar objects, people, and places, which significantly impacts their daily functioning and independence.
Correct Answer is B
Explanation
Choice A reason:
The statement "A unit secretary who speaks the same language as the client" is not the best option. While the unit secretary may be able to communicate in the client's language, they may not have the necessary training in medical terminology and confidentiality required for effective and accurate translation in a healthcare setting.
Choice B reason:
The statement "A translator of the same gender as the client" is the correct response. A professional translator is trained in medical terminology, confidentiality, and cultural sensitivity, ensuring accurate and effective communication. Choosing a translator of the same gender can also help the client feel more comfortable, especially when discussing sensitive topics.
Choice C reason:
The statement "Another client who speaks the same language as the client" is not appropriate. Using another client as a translator can breach confidentiality and may not provide accurate translation due to a lack of medical knowledge and training.
Choice D reason:
The statement "A family member of the client" is not the best option. While family members can help with communication, they may not be objective and could potentially misinterpret or withhold information. Additionally, using family members can compromise the client's privacy and confidentiality.
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