During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, “I’m thinking about suicide.” Which nursing intervention takes priority?

Teach the client relaxation techniques.

Ask the client, “Do you have a plan to commit suicide?”

Call the physician to obtain a PRN order for an anxiolytic medication.

Encourage the client to participate in group activities.

Answer and Explanation

The Correct Answer is B

Suicidal ideation in the context of generalized anxiety disorder (GAD) is a psychiatric emergency requiring immediate risk assessment. GAD is characterized by excessive, persistent worry and physiological symptoms such as restlessness, fatigue, and sleep disturbance. When suicidal thoughts are present, especially with high anxiety and low mood ratings, the priority is to determine intent and plan. This guides the urgency of intervention and safety measures.

Rationale for correct answers

2. Suicide risk and intent assessment must be addressed first. Determining whether the client has a plan helps evaluate lethality and immediacy. This guides whether one-to-one observation, hospitalization, or other protective measures are needed.

Rationale for incorrect answers

1. Teaching relaxation techniques is inappropriate when suicide risk is active. It does not address the immediate safety concern and assumes the client is stable enough to engage in coping strategies.

3. Calling for a PRN anxiolytic may help reduce anxiety but does not address the suicidal ideation directly. Medication alone is insufficient without assessing intent and planning.

4. Encouraging group participation is a long-term therapeutic strategy. It is not suitable during acute suicidal ideation and may overwhelm the client or increase distress.

Take Home Points

Suicide risk assessment begins with direct questioning about intent and plan.
Generalized anxiety disorder increases suicide risk, especially with comorbid depression.
Immediate safety interventions take precedence over therapeutic or pharmacologic measures.
Relaxation and group therapy are supportive but secondary to crisis evaluation.

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Correct Answer is ["A","B","E"]

Explanation

Generalized anxiety disorderis a chronic psychiatric condition marked by excessive worry, muscle tension, and autonomic hyperarousal. According to DSM-5, symptoms must persist for at least six months and include difficulty controlling worry, restlessness, fatigue, irritability, sleep disturbance, and somatic complaints. Feeling “keyed up” or “on edge” reflects persistent sympathetic activation. Muscle tension is a hallmark physical symptom. Hypersomnia and excessive energy are not typical features and may suggest alternative diagnoses like depression or bipolar disorder.

Rationale for correct answers

1. Excessive worryis the core diagnostic feature of generalized anxiety disorder. It must be present most days for at least six months and be difficult to control.

2. Muscle tensionis one of the six DSM-5 physical symptoms used to validate the diagnosis. It reflects chronic somatic arousal and is commonly reported.

5. Feeling “keyed up”or “on edge” indicates autonomic hyperactivity and is part of the DSM-5 criteria. It reflects the persistent restlessness and arousal seen in GAD.

Rationale for incorrect answers

3.Hypersomniais more characteristic of depressive disorders. GAD typically presents with insomnia or restless, unsatisfying sleep.

4.Excessive energyis not a symptom of GAD. It may suggest manic or hypomanic episodes seen in bipolar spectrum disorders.

Take Home Points

Generalized anxiety disorder requires excessive, uncontrollable worry lasting at least six months.
DSM-5 criteria include restlessness, fatigue, irritability, muscle tension, sleep disturbance, and difficulty concentrating.
Feeling “keyed up” and muscle tension are hallmark signs of autonomic arousal in GAD.

A. “The client appears calm, vital signs within normal limits, no diaphoresis noted.” B. “The client states that the breathing techniques used helped to decrease anxiety.” C. “The client is able to recognize negative self-talk as a sign of increased anxiety.” D. “The client uses journaling to express frustrations.”

Correct Answer is C

Explanation

Cognitive responserefers to how a client processes, interprets, and applies information or strategies learned during care. In generalized anxiety disorder (GAD), cognitive responses are essential for long-term management and include identifying triggers, restructuring thoughts, and recognizing maladaptive patterns. GAD is marked by excessive worry, restlessness, and difficulty concentrating, often accompanied by somatic symptoms. Cognitive-behavioral therapy (CBT) is the gold standard, targeting distorted thinking and promoting adaptive coping. A key goal is helping clients identify negative self-talk, which perpetuates anxiety and impairs functioning. Discharge planning should assess whether clients can apply these cognitive strategies independently.

Rationale for correct answers

3.Thought recognitionand self-awarenessreflect cognitive processing. The ability to identify negative self-talk indicates the client has internalized cognitive strategies taught during therapy, showing readiness for discharge and independent coping.

Rationale for incorrect answers

1.This describes physiological stability, not cognitive processing. While calm demeanor and normal vitals are positive, they do not reflect the client’s internal thought patterns or ability to manage anxiety cognitively.

2.This reflects behavioral feedback, not cognitive restructuring. While breathing techniques are helpful, stating their effectiveness does not demonstrate insight into thought patterns or triggers.

4.Journaling is an expressive and emotional outlet. It supports emotional regulation but does not directly evaluate cognitive restructuring or thought monitoring, which are central to cognitive response.

Take Home Points

Cognitive response involves recognizing and restructuring maladaptive thoughts that fuel anxiety.
Physiological and behavioral improvements do not confirm cognitive readiness for discharge.
Identifying negative self-talk is a key marker of cognitive progress in GAD.

Journaling and relaxation techniques support emotional regulation but are not direct indicators of cognitive restructuring.

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During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, “I’m thinking about suicide.” Which nursing intervention takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following symptom assessments would validate the diagnosis of generalized anxiety disorder? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A client diagnosed with generalized anxiety disorder is getting ready for discharge. Which statement evaluates the client’s cognitive response to nursing interventions?

Correct Answer is C

Explanation

In the United States, which diagnosis has the lowest percentage of occurrence?

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During an assessment, a client diagnosed with generalized anxiety disorder rates anxiety as 9/10 and states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority?