A nurse in an urgent care clinic is caring for a client who is using loud and rapid speech and continuously repeats, "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing?
Moderate
Panic
Severe
Mild
The Correct Answer is A
Moderate. According to the Mayo Clinic moderate anxiety is characterized by symptoms such as loud and rapid speech, difficulty concentrating, restlessness, and increased worry. The client's behavior matches these symptoms, indicating that they are experiencing moderate anxiety.
Choice B. Panic is incorrect because panic is a severe form of anxiety that involves symptoms such as chest pain, shortness of breath, trembling, and a sense of impending doom. The client does not exhibit these symptoms.
Choice C. Severe is incorrect because severe anxiety is marked by symptoms such as irrational fear, detachment from reality, hallucinations, and loss of control¹². The client does not show these symptoms.
Choice D. Mild is incorrect because mild anxiety is associated with symptoms such as nervousness, increased alertness, and slight discomfort¹². The client's symptoms are more intense than mild anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density.
Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
Options A, B, and C are incorrect findings in a client with anorexia nervosa. Decreased cholesterol levels may be an indication of malnutrition. Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss. Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
Correct Answer is D
Explanation
Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Choice A, placing the client in a private room, does not address the client’s physical needs.
Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.
Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.
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