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 A

Explanation

A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.

B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.

C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.

A. Remain with the client. B. Give to client a PRN sleeping medication, C. Encourage the client to go back to bed. D. Explore alternatives to pacing the floor with the client.

Correct Answer is A

Explanation

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

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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 providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

Correct Answer is A

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Correct Answer is A

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