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. Borderline personality disorder. Borderline personality disorder falls under Cluster B, which includes dramatic, emotional, and erratic disorders. Individuals with this disorder often exhibit impulsivity, intense emotional instability, fear of abandonment, and unstable relationships.
B. Antisocial personality disorder. Antisocial personality disorder is part of Cluster B and is characterized by a disregard for social norms, lack of empathy, and manipulative or deceitful behavior. Individuals with this disorder often engage in impulsive and irresponsible actions.
C. Dependent personality disorder. Dependent personality disorder belongs to Cluster C, which includes anxious and fearful disorders. Individuals with this disorder exhibit excessive reliance on others, difficulty making decisions, and an intense fear of abandonment, leading to submissive and clingy behavior.
D. Paranoid personality disorder. Paranoid personality disorder is categorized under Cluster A, which consists of odd and eccentric personality disorders. It is characterized by pervasive distrust, suspicion of others, and a tendency to interpret others' actions as malicious.
Correct Answer is C
Explanation
A. Stimulants. Stimulant intoxication typically causes increased energy, agitation, tachycardia, and paranoia, but it does not usually induce hallucinations to the extent described. While severe stimulant use (e.g., methamphetamine or cocaine) can cause paranoia, the significant perceptual disturbances and visual hallucinations suggest a different category of drugs.
B. Opioids. Opioid intoxication generally leads to central nervous system depression, respiratory depression, pinpoint pupils, and sedation rather than paranoia, hallucinations, and erratic behavior. The described symptoms do not align with opioid use.
C. Hallucinogens. Hallucinogen use, such as LSD or PCP, can cause altered perception, paranoia, visual hallucinations, and erratic behavior. The client’s symptoms—paranoia, visual disturbances, mumbling, and gesturing—are characteristic of hallucinogen intoxication, making this the most likely cause.
D. Anabolic steroids. Anabolic steroid use can lead to mood swings, aggression, and psychotic symptoms in some cases, but it does not typically cause acute hallucinations, paranoia, or perceptual disturbances. The symptoms described do not fit anabolic steroid use.
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