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 A
Explanation
Choice A rationale:
Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.
Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:
Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:
Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:
Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.
Correct Answer is D
Explanation
Choice A rationale:
Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.
It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.
It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.
Choice B rationale:
Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.
It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.
It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.
Choice C rationale:
Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.
It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.
It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.
Choice D rationale:
Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.
It reflects an inability to cope with disappointment or setbacks in a constructive way.
It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.
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