A nurse on an inpatient mental health unit is assisting with the care of a client who is experiencing panic level anxiety. Which of the following findings should the nurse expect?
Voice tremors
Depersonalization
Shakiness
Poor concentration
The Correct Answer is B
A. Voice tremors are associated with moderate anxiety, where the individual begins to exhibit physical signs of distress but still retains some level of focus. At panic-level anxiety, communication becomes severely impaired, often resulting in unintelligible speech or complete loss of verbal ability.
B. Depersonalization, a dissociative symptom in which individuals feel detached from their own body or reality, is a hallmark of panic-level anxiety. During this state, individuals may experience a sense of unreality, feel as though they are outside their body, or believe that their surroundings are distorted, contributing to a profound sense of fear and disorientation.
C. Shakiness is a physiological response observed in moderate to severe anxiety due to increased autonomic arousal. However, at panic-level anxiety, the body is in a state of extreme crisis, often leading to more severe symptoms such as hyperventilation, loss of motor control, and derealization rather than mere shakiness.
D. Poor concentration is characteristic of moderate to severe anxiety, where cognitive function begins to decline due to excessive worry. However, in panic-level anxiety, cognitive function is severely impaired, and the individual may be unable to process information coherently, often leading to complete disorganization of thought.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The procedure will take about 2 hours.": A typical transcranial magnetic stimulation (TMS) session lasts about 30 to 40 minutes. The treatment is conducted on an outpatient basis, allowing clients to resume daily activities immediately afterward.
B. "Most people only require one treatment to eliminate their depression.": TMS is typically administered in multiple sessions over several weeks. A full course usually consists of daily treatments for four to six weeks to achieve significant symptom improvement.
C. "You may experience a mild headache following the procedure.": Mild headaches and scalp discomfort are common side effects of TMS due to repeated magnetic pulses stimulating the brain. These effects are generally temporary and can be managed with over-the-counter analgesics.
D. "You will be asleep during the procedure.": TMS does not require sedation or anesthesia. Clients remain awake and alert during the procedure, as the treatment is noninvasive and does not cause significant discomfort requiring sedation.
Correct Answer is B
Explanation
A. "Medication compliance.": While medications can help manage mood instability or co-occurring conditions like depression or anxiety, they are not the primary treatment for borderline personality disorder (BPD). The primary focus should be on addressing immediate safety concerns, including self-harm and suicidal tendencies, which are more urgent.
B. "Awareness of potential for self-harm.": Clients with BPD frequently engage in self-harming behaviors or suicidal gestures due to emotional dysregulation, impulsivity, and intense fear of abandonment. Educating the family about recognizing warning signs, providing emotional support, and ensuring access to crisis intervention resources is critical for reducing risk and promoting safety.
C. "Information about insurance coverage.": While understanding insurance coverage can help in accessing long-term treatment, it is not the most urgent need when addressing the safety of a client newly diagnosed with BPD. Immediate interventions should focus on risk assessment and prevention of harmful behaviors.
D. "Resources for group therapy in the community.": Group therapy, such as dialectical behavior therapy (DBT), can be beneficial for long-term symptom management, but in the early stages of diagnosis, ensuring the family's awareness of self-harm risks and how to intervene in a crisis takes priority over therapy referrals.
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