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
Choice A rationale:
Shellfish is generally safe for clients taking MAOIs. However, it's important to ensure shellfish is fresh and properly refrigerated to avoid tyramine buildup due to spoilage.
Some individuals with shellfish allergies may need to avoid it regardless of MAOI use.
Choice B rationale:
Milk and milk products are typically safe for clients taking MAOIs.
However, some aged cheeses, such as cheddar, Swiss, and Parmesan, can contain high levels of tyramine and should be avoided.
Choice C rationale:
Canned tuna is generally safe for clients taking MAOIs.
However, it's essential to check labels carefully, as some brands may contain added tyramine-rich ingredients like soy sauce or fermented flavorings.
Choice D rationale:
Aged cheeses contain high levels of tyramine, an amino acid that can interact with MAOIs and cause a hypertensive crisis.
This is a potentially life-threatening condition characterized by a sudden and severe increase in blood pressure.
It's crucial for clients taking MAOIs to avoid all aged cheeses, including cheddar, Swiss, Parmesan, blue cheese, feta, and others.
Correct Answer is ["C","D"]
Explanation
Choice C rationale:
Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.
Rationale for Immediate
Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.
Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.
Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.
Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.
Choice D rationale:
Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.
Rationale for Immediate
Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).
Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.
Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.
Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.
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