The nurse observes a client who is rapidly pacing, wringing their hands, and trembling. Their speech is high-pitched, they are unable to concentrate, and have restricted problem-solving. The nurse identifies the client’s anxiety level as:

Mild

Panic

Moderate

Severe

Answer and Explanation

The Correct Answer is B

Choice A reason: Mild anxiety is characterized by slight restlessness or discomfort, with intact concentration and problem-solving abilities. The client’s symptoms, including rapid pacing, trembling, and inability to concentrate, indicate a more intense physiological and cognitive impairment, ruling out mild anxiety as the correct assessment.

Choice B reason: Panic-level anxiety involves extreme physiological arousal, with symptoms like rapid pacing, trembling, high-pitched speech, and inability to concentrate or problem-solve. These reflect a severe sympathetic nervous system response, overwhelming the client’s ability to function, making panic the most accurate description of the client’s state.

Choice C reason: Moderate anxiety involves noticeable discomfort, with some difficulty concentrating but retained problem-solving ability. The client’s severe symptoms, including high-pitched speech and restricted problem-solving, exceed this level, indicating a more intense state of anxiety that aligns with panic rather than moderate anxiety.

Choice D reason: Severe anxiety includes significant distress and impaired function but typically allows some concentration and problem-solving, unlike panic. The client’s extreme symptoms, such as inability to concentrate and restricted problem-solving, suggest a higher level of distress consistent with a panic state.

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Correct Answer is D

Explanation

Choice A reason: Difficulty focusing and helplessness are depressive symptoms, but flight of ideas is characteristic of mania, not major depression. This combination does not fully align with the diagnosis, as mania involves elevated mood, which is inconsistent with the client’s statement.

Choice B reason: Depressed mood and guilt are hallmarks of major depression, but pressured speech is a manic symptom, involving rapid, excessive talking. This does not correlate with the anhedonic, low-energy presentation of major depression described by the client.

Choice C reason: Changes in sleep pattern and fatigue are common in depression, but grandiose mood is a manic feature, not associated with major depression. This contradicts the client’s anhedonia, making this combination inconsistent with the diagnosis of major depression.

Choice D reason: Anhedonia (loss of pleasure), feelings of worthlessness, and difficulty focusing are core symptoms of major depression, reflecting altered serotonin and dopamine levels affecting mood, self-perception, and cognition. These align with the client’s statement and the diagnosis, making this the correct choice.

A. Pulmonary edema B. Dependent edema C. Abdominal swelling D. Dry cough E. Distended neck veins

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

Explanation

Choice A reason: Pulmonary edema is associated with left-sided heart failure, where blood backs up into the lungs, causing fluid leakage and crackles. Right-sided heart failure primarily affects systemic venous return, leading to peripheral and abdominal fluid accumulation, not pulmonary edema, making this inconsistent with the diagnosis.

Choice B reason: Dependent edema, such as ankle or leg swelling, occurs in right-sided heart failure due to impaired right ventricular pumping, causing blood to back up in systemic veins. This leads to fluid leakage into peripheral tissues, a hallmark symptom consistent with right-sided heart failure.

Choice C reason: Abdominal swelling, or ascites, results from right-sided heart failure due to increased venous pressure in the systemic circulation, causing fluid accumulation in the peritoneal cavity. This is a common and consistent finding, reflecting the systemic congestion caused by right heart dysfunction.

Choice D reason: Dry cough is typically associated with left-sided heart failure due to pulmonary edema irritating the airways. Right-sided heart failure causes systemic venous congestion, not pulmonary fluid buildup, so dry cough is not a primary or consistent symptom of this condition.

Choice E reason: Distended neck veins (jugular vein distension) occur in right-sided heart failure due to increased systemic venous pressure from impaired right ventricular emptying. This is a key clinical sign, reflecting the backup of blood in the venous system, consistent with right-sided heart failure.

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The nurse observes a client who is rapidly pacing, wringing their hands, and trembling. Their speech is high-pitched, they are unable to concentrate, and have restricted problem-solving. The nurse identifies the client’s anxiety level as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with a diagnosis of major depression and states, “Nothing brings me pleasure anymore.” Which behaviors will the nurse assess that correlate with the diagnosis?

Correct Answer is D

Explanation

The nurse is assessing a client who has a history of right-sided heart failure. Which assessment finding(s) is/are most consistent with this client’s diagnosis? (Select all that apply)

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

Explanation

The best goal for a client learning a relaxation technique is that the client will

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