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 B
Explanation
Choice A rationale:
Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.
It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.
Choice B rationale:
Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.
Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.
It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.
Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.
Choice C rationale:
Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.
It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.
However, it would not typically be the most urgent finding requiring immediate intervention.
Choice D rationale:
Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.
It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.
However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.
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