A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

Generalized anxiety disorder and a nursing diagnosis of fear

Panic disorder and a nursing diagnosis of panic anxiety

Pain disorder and a nursing diagnosis of altered role performance

Altered sensory perception and a nursing diagnosis of panic disorder

Answer and Explanation

The Correct Answer is B

A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.

B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.

C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.

D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.

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Correct Answer is A

Explanation

A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.

B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.

C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.

D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.

A. I understand that you are angry, but this behavior will not be tolerated B. You are very disrespectful. You need to learn to control yourself. C. What behaviors could you modify to improve this situation? D. What anti-personality disorder medications have helped you in the past

Correct Answer is A

Explanation

A. "I understand that you are angry, but this behavior will not be tolerated": This response sets a clear boundary regarding unacceptable behavior while acknowledging the client's emotional state. It communicates to the client that their actions are not acceptable, but it does so in a firm yet empathetic manner. This statement also maintains professionalism and ensures a safe and respectful environment for both the client and the nurse.

B. "You are very disrespectful. You need to learn to control yourself": This statement is confrontational and may escalate the client's anger or resistance. It focuses on blaming the client rather than exploring potential modifications to improve the situation.

C. "What behaviors could you modify to improve this situation?":may not be as effective in this context because it places the responsibility solely on the client to modify their behavior without directly addressing the inappropriate actions exhibited. Additionally, individuals with antisocial personality disorder may have difficulty recognizing the impact of their behavior on others or may be resistant to changing their actions without external intervention or consequences.

D. "What anti-personality disorder medications have helped you in the past?": Antisocial personality disorder is not typically treated with specific medications, and individuals with this disorder may not seek or comply with medication interventions. Asking about medications may not be relevant or helpful in addressing the immediate behavioral issues.

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A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

Correct Answer is A

Explanation

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior?

Correct Answer is A

Explanation

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A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority?

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

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