A nurse is caring for a client who has an anxiety disorder.
Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
Insomnia
Chest pain
C. Irritability
Incoherent speech
The Correct Answer is C
Choice A rationale:
Insomnia is a common symptom of anxiety, but it is not typically seen in mild cases. It is more often associated with moderate to severe anxiety.
When anxiety is mild, individuals may experience difficulty falling asleep or staying asleep, but they are not typically unable to sleep at all.
Other sleep-related symptoms of mild anxiety may include restlessness, nightmares, or early morning awakening.
Choice B rationale:
Chest pain is a serious symptom that can be caused by a variety of medical conditions, including anxiety. However, it is not a common manifestation of mild anxiety.
Chest pain associated with anxiety is typically described as a sharp, stabbing pain or a feeling of tightness in the chest. It may be accompanied by other symptoms such as shortness of breath, palpitations, or sweating.
If a client with anxiety is experiencing chest pain, it is important to rule out other potential causes, such as heart disease or a pulmonary embolism.
Choice D rationale:
Incoherent speech is a sign of severe anxiety or a panic attack. It is not typically seen in mild anxiety.
When a person is experiencing incoherent speech, they may have difficulty speaking in complete sentences or making sense of their thoughts. They may also slur their words or speak in a rapid, disjointed manner.
Choice C rationale:
Irritability is a common manifestation of mild anxiety. It is often characterized by a feeling of being easily annoyed or angered.
Individuals with mild anxiety may also be more impatient, short-tempered, or argumentative than usual.
They may also have a lower tolerance for frustration and stress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Telling the client to work hard to stay on the schedule does not address the underlying reasons for the client's difficulty in following a medication regimen and may come off as dismissive.
Choice B rationale: Saying not to worry about the past does not acknowledge the client's concerns and may not provide practical assistance for future adherence.
Choice C rationale: Offering reassurance without addressing the client's past challenges does not provide a concrete plan for improving adherence.
Choice D rationale: Asking the client why they find it difficult to take medications opens a dialogue that allows the nurse to understand the client's specific barriers and to provide tailored strategies to improve adherence. This response is empathetic and solution-focused.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.
Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.
Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.
Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.
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