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. Increased cheerfulness, increased energy, helping other nurses on the shift. While mood changes can sometimes indicate a problem, increased cheerfulness and willingness to help others are not specific red flags for substance use disorder. Substance use is more commonly associated with erratic behavior, frequent absences, or medication discrepancies.
B. Increased irritability towards supervisors, outspokenness regarding work issues, increased attendance at staff meetings. Frustration with workplace issues and increased engagement in staff meetings do not necessarily indicate substance use disorder. Behavioral concerns related to substance use often include impaired judgment, frequent errors, or missing narcotics.
C. Volunteering for overtime on a continual basis, avoiding having a witness to wasting narcotics, needing to be alone in the medication room when preparing medications. Consistently seeking extra shifts, avoiding witnesses when handling narcotics, and needing to be alone while preparing medications suggest possible drug diversion. These behaviors align with common patterns seen in healthcare professionals struggling with substance use disorders.
D. Crying, sharing personal details of relationship problems, monopolizing conversations. Emotional distress and oversharing personal issues may indicate stress or burnout rather than substance use disorder. Substance use concerns are more closely tied to inconsistent work performance, medication discrepancies, and altered behavior related to drug access.
Correct Answer is D
Explanation
A. Depression. Depression is typically characterized by low energy, feelings of sadness, and withdrawal from activities. Hyperactivity and pacing are not consistent with depressive symptoms, as individuals with depression often exhibit psychomotor retardation rather than excessive movement.
B. Delusions. Delusions are fixed, false beliefs that are not based on reality, such as paranoia or grandiosity. While delusions can occur in mania, the client's primary symptoms of hyperactivity, pacing, and poor concentration are more indicative of a manic episode rather than delusional thinking alone.
C. Hallucinations. Hallucinations involve sensory perceptions that occur without external stimuli, such as hearing voices or seeing things that are not there. The client’s symptoms do not indicate hallucinations but rather heightened activity levels and distractibility.
D. Mania. Mania is characterized by hyperactivity, excessive energy, rapid speech, and poor concentration. Pacing and an inability to focus during group therapy suggest an elevated mood state, making mania the most appropriate identification of the client’s manifestations.
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