A 23-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety:

is pathologic and warrants postponing the test.

may be transferred to their classmates and result in generalized anxiety disorder.

will interfere with their cognitive ability.

is conducive to concentration and problem-solving.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Labeling mild anxiety as pathologic and suggesting that it warrants postponing the test is not accurate. Mild anxiety is a normal response to stress and can actually be beneficial in certain situations. It helps to increase alertness and focus, which can improve performance on tasks such as taking a test. Pathologic anxiety, on the other hand, is excessive and persistent, interfering with daily functioning and requiring clinical intervention.

Choice B Reason:

The idea that mild anxiety may be transferred to classmates and result in generalized anxiety disorder is not supported by evidence. Anxiety is a personal experience and while it can be influenced by the environment, it is not something that can be directly transferred from one person to another. Generalized anxiety disorder is a chronic condition characterized by excessive worry about various aspects of life, and it develops due to a combination of genetic, environmental, and psychological factors.

Choice C Reason:

While severe anxiety can interfere with cognitive ability, mild anxiety typically does not. In fact, mild anxiety can enhance cognitive performance by increasing alertness and focus. It is only when anxiety becomes overwhelming that it starts to impair cognitive functions such as memory, attention, and problem-solving.

Choice D Reason:

Mild anxiety is conducive to concentration and problem-solving. This level of anxiety can act as a motivator, helping individuals to focus better and perform tasks more efficiently. The Yerkes-Dodson law suggests that there is an optimal level of arousal (including anxiety) that enhances performance. Too little arousal can lead to underperformance, while too much can cause performance to deteriorate.

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Correct Answer is A

Explanation

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

A. Increase external stimuli. B. Stay with the client and speak to them in a calm manner. C. Allow the client to have their requested space. D. Review the updated problem list with the client.

Correct Answer is B

Explanation

Choice A Reason:

Increase external stimuli.

Increasing external stimuli is not appropriate during a panic attack. Panic attacks are characterized by intense fear and anxiety, often accompanied by physical symptoms such as rapid heartbeat, sweating, and shortness of breath. Increasing external stimuli can exacerbate these symptoms and heighten the client’s distress. The goal during a panic attack is to reduce stimuli and create a calming environment to help the client regain control.

Choice B Reason:

Stay with the client and speak to them in a calm manner.

This is the correct response. Staying with the client and speaking to them in a calm manner provides reassurance and helps to ground them during the panic attack. The presence of a calm and supportive nurse can help reduce the client’s anxiety and provide a sense of safety. This approach aligns with therapeutic communication techniques and is effective in managing acute anxiety episodes.

Choice C Reason:

Allow the client to have their requested space.

While it is important to respect a client’s need for space, leaving them alone during a panic attack may not be the best approach. Clients experiencing panic attacks may feel overwhelmed and frightened, and the presence of a supportive nurse can help them feel safer and more secure. It is important to balance the client’s need for space with the need for support and reassurance.

Choice D Reason:

Review the updated problem list with the client.

Reviewing the updated problem list is not appropriate during a panic attack. This action requires cognitive engagement and focus, which the client may not be capable of during an acute anxiety episode. The priority during a panic attack is to help the client calm down and manage their immediate symptoms, not to discuss or review problems.

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A 23-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety:

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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