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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Increased salivation is a common side effect of haloperidol, but it is not the most serious adverse effect that the nurse should monitor for. It can be managed with medications such as anticholinergics, and it often subsides with continued use of haloperidol. Choice B rationale:

Serotonin syndrome is a rare but potentially life-threatening condition that can occur when haloperidol is combined with other medications that increase serotonin levels, such as antidepressants. However, it is not a direct adverse effect of haloperidol itself.

Choice C rationale:

Increased menstrual bleeding is not a known side effect of haloperidol.

Choice D rationale:

Tardive dyskinesia is a serious and potentially irreversible movement disorder that can occur as a long-term side effect of haloperidol and other antipsychotic medications. It is characterized by involuntary, repetitive movements of the face, tongue, and limbs.

The risk of tardive dyskinesia increases with the length of time that a person takes haloperidol and with the dose of the medication.

There is no cure for tardive dyskinesia, but the symptoms can sometimes be managed with medications.

It is important for nurses to monitor patients who are taking haloperidol for signs of tardive dyskinesia, so that the medication can be discontinued if necessary.

A. Place the client in seclusion if she is experiencing visual hallucinations. B. Minimize staff supervision of the client’s interactions with others. C. Directly tell the client that delusions are not real. D. Limit the client’s participation in group activities.

Correct Answer is D

Explanation

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

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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?