A nurse at a walk in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

Attention-seeking conduct

Wild fidgeting

Threatening behavior

Mild difficulty problem solving

Answer and Explanation

The Correct Answer is B

A. In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.

B. Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.

C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.

D. Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.

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Correct Answer is D

Explanation

While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.

B. Applying a cooling blanket.

While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.

C. Administering an anticonvulsant.

While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.

D. Preparing for artificial ventilation.

Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.

A. "You've been feeling that your life has no meaning." B. "You have a great deal to live for." C. "It's not unusual for depressed people to feel that way." D. "Why do you feel you are worthless?"

Correct Answer is A

Explanation

A."You've been feeling that your life has no meaning."This response reflects active listening and acknowledges the client's emotions. Itreflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.

B. "You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.

C. "It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.

D. "Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.

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A nurse at a walk in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

Correct Answer is D

Explanation

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

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