The nurse has received an evening report. Which client would the nurse need to assess first?

A newly admitted client with a history of panic attacks.

A client who slept 2 to 3 hours last night because of flashbacks.

A client pacing the halls and stating that his anxiety is an 8/10.

A client diagnosed with generalized anxiety disorder awaiting discharge.

Answer and Explanation

The Correct Answer is C

Acute anxiety escalation requires immediate nursing attention due to its potential to progress into panic or behavioral dysregulation. When a client verbalizes a high anxiety rating (e.g. 8/10) and exhibits pacing, this signals autonomic hyperarousal, impaired coping, and possible risk of harm to self or others. Anxiety activates the sympathetic nervous system, leading to increased heart rate, blood pressure, and respiratory rate. If unaddressed, it can impair judgment, escalate into panic attacks, or trigger aggression. Nursing priority is guided by Maslow’s hierarchy—physiological and safety needs come first. Clients with acute symptoms must be stabilized before addressing chronic or less urgent concerns.

Rationale for correct answers

3. Elevated anxiety and pacing behavior indicate acute distress. The client is actively symptomatic and may be at risk for decompensation. Immediate assessment allows for early intervention, de-escalation, and prevention of harm.

Rationale for incorrect answers

1. Although newly admitted clients require prompt assessment, a history of panic attacks alone does not indicate current instability. Without active symptoms, this client is not the highest priority.

2. Sleep disruption due to flashbacks suggests PTSD-related distress, but the client is not currently exhibiting acute behavioral or physiological symptoms. This is important but not urgent.

4. A client awaiting discharge with a diagnosis of GAD is likely stable and has already been evaluated for readiness. Discharge planning is a lower priority compared to acute symptom management.

Take Home Points

Clients with acute anxiety symptoms (e.g. pacing, high self-reported anxiety) require immediate assessment to prevent escalation.
Prioritization is based on physiological and safety needs per Maslow’s hierarchy.
History alone does not determine urgency—current presentation is key.
Sleep disruption and chronic anxiety are important but not prioritized over acute behavioral signs.

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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. Recognize the signs associated with an elevation in mood. B. Learn to obtain assistance when his anxiety is increasing. C. Develop guidelines for decreasing manipulative behavior of peers. D. Explore ways to facilitate participation in self-care activities.

Correct Answer is B

Explanation

Generalized anxiety disorder (GAD)is a chronic psychiatric condition marked by excessive, uncontrollable worry occurring more days than not for at least 6 months. It involves both psychological distressand somatic symptomssuch as restlessness, fatigue, and muscle tension. Management includes pharmacologic and non-pharmacologic interventions, with emphasis on early recognitionof symptom escalation and implementation of coping strategies to prevent functional impairment.

Rationale for correct answers

2.Learning to obtain assistance when anxiety increases reflects insight and self-monitoring, which are essential for relapse prevention. It promotes adaptive copingand timely intervention before symptoms escalate.

Rationale for incorrect answers

1.Recognizing signs of elevated mood is relevant to bipolar disorder, not GAD. GAD is characterized by persistent worry, not mood elevation or pressured speech.

3.Decreasing manipulative peer behavior is unrelated to GAD. This goal aligns more with personality disorders or conduct-related interventions.

4.Facilitating self-care participation is more applicable to depressive disordersor severe psychosis where motivation and functioning are impaired. GAD clients typically maintain self-care but struggle with excessive worry.

Take Home Points

GAD clients benefit from learning to recognize symptom escalation and seek support proactively.
Elevated mood and pressured speech are features of bipolar disorder, not GAD.
Goals should align with the client’s diagnosis and functional challenges specific to anxiety.
Self-care deficits are not primary in GAD unless comorbid depression is present.

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The nurse has received an evening report. Which client would the nurse need to assess first?

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

After a nurse teaches a client with generalized anxiety disorder some strategies for coping with stressors, another goal for the client would be to:

Correct Answer is B

Explanation

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

A client diagnosed with generalized anxiety disorder has a nursing diagnosis of panic anxiety related to altered perceptions. Which of the following short-term outcomes is most appropriate for this client?

The nurse has received an evening report. Which client would the nurse need to assess first?

Which assessment information would be evaluated as objective data?

After a nurse teaches a client with generalized anxiety disorder some strategies for coping with stressors, another goal for the client would be to:

A client diagnosed with generalized anxiety disorder is placed on clonazepam (Klonopin) and buspirone (BuSpar). Which client statement indicates teaching has been effective?

A client recently diagnosed with generalized anxiety disorder is prescribed clonazepam (Klonopin), buspirone (BuSpar), and citalopram (Celexa). Which assessment related to the concurrent use of these medications is most important?

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?