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 ["A","B","C","D","E","F","G"]
Explanation
The client’s return for a follow-up examination after new onset of symptoms indicates a change in their health status that requires immediate attention.
Loss of appetite can be a sign of various health issues, including depression and other mental health disorders1. It’s important to address this symptom promptly to ensure the client is receiving proper nutrition.
Excessive sleepiness can be a symptom of several conditions, including depression, sleep disorders, and certain medical conditions1. It’s important to investigate this symptom further to determine its cause.
Becoming teary when asked about plans for activities could indicate emotional distress or depression. Mental health is a critical aspect of overall health, and this symptom should be addressed promptly.
Questioning the reason to live if not working is a serious symptom that could indicate suicidal ideation
This requires immediate attention and intervention.
While a dry, nonproductive cough can be a symptom of a respiratory condition, since breath sounds are present bilaterally, it may not require immediate attention. However, any persistent cough should be evaluated.
Occasional muscle aches and pains can be a symptom of various conditions, including fibromyalgia, influenza, and other infections1. It’s important to investigate this symptom further to determine its cause.
Reporting no energy could be a symptom of conditions such as depression, chronic fatigue syndrome, or anemia. This symptom should be addressed promptly to determine its cause and appropriate treatment.
Correct Answer is B
Explanation
Choice A reason:
The statement "Identify when the client engages in splitting behaviors" is not appropriate for schizoid personality disorder. Splitting behaviors are more commonly associated with borderline personality disorder, where individuals may view others as all good or all bad. Schizoid personality disorder is characterized by a preference for solitary activities and emotional detachment.
Choice B reason:
The statement "Give the client a choice of solitary activities" is the correct response. Individuals with schizoid personality disorder often prefer solitary activities and may feel more comfortable engaging in them. Providing options for solitary activities respects their preferences and helps them feel more at ease in the care environment.
Choice C reason:
The statement "Assist the client in identifying sources of anger" is not typically relevant for schizoid personality disorder. These individuals often appear emotionally detached and may not express anger or other strong emotions openly. This intervention is more suited for personality disorders where emotional dysregulation is a primary concern.
Choice D reason:
The statement "Set limits on the client's need for constant social contact with others" is not applicable. Clients with schizoid personality disorder usually do not seek constant social contact; instead, they prefer to be alone and avoid social interactions. Setting limits on social contact is unnecessary and does not address their primary needs.
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