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NurseDive Free Nursing Practice Question
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?
A. Panic.
Panic. Panic-level anxiety typically involves extreme fear and severe physical symptoms such as palpitations, sweating, trembling, and a sense of impending doom. The client's reported symptoms (chest pain, headache, shortness of breath) do not align with the intense nature of panic anxiety.
B. Mild.
Mild. Mild anxiety is characterized by heightened awareness and alertness. The client's symptoms and statement about his wife leaving him suggest more than mild anxiety as they indicate emotional distress beyond simple alertness.
C. Moderate.
Moderate. Moderate anxiety is associated with increased muscle tension, restlessness, and impaired concentration. Moderate anxiety (choice C) is characterized by increased alertness and decreased concentration but is manageable with support. .
D. Severe.
Severe.Severe anxiety significantly impairs daily functioning. It can cause physical symptoms such as chest pain, shortness of breath, and headaches. The client’s presentation aligns with severe anxiety, given the impact on his well-being
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Full Explanation
A. Panic. Panic-level anxiety typically involves extreme fear and severe physical symptoms such as palpitations, sweating, trembling, and a sense of impending doom. The client's reported symptoms (chest pain, headache, shortness of breath) do not align with the intense nature of panic anxiety.
B. Mild. Mild anxiety is characterized by heightened awareness and alertness. The client's symptoms and statement about his wife leaving him suggest more than mild anxiety as they indicate emotional distress beyond simple alertness.
C. Moderate. Moderate anxiety is associated with increased muscle tension, restlessness, and impaired concentration. Moderate anxiety (choice C) is characterized by increased alertness and decreased concentration but is manageable with support.
D. Severe anxiety significantly impairs daily functioning. It can cause physical symptoms such as chest pain, shortness of breath, and headaches. The client’s presentation aligns with severe anxiety, given the impact on his well-being.
Similar Questions
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?
A. Prepare for gastric lavage due to an extremely elevated lithium level.
A lithium level of 1.0 mEq/L is within the therapeutic range (0.6-1.2 mEq/L) and does not require gastric lavage. Gastric lavage is used in cases of severe toxicity.
B. Administer the morning dose of lithium.
A lithium level of 1.0 mEq/L is therapeutic, so the nurse should administer the morning dose as prescribed. The client has been on lithium for 2 weeks, and maintaining consistent blood levels is important for therapeutic effectiveness.
C. Check the client's medication record to assess whether the client has been refusing her lithium.
This is unnecessary. The lithium level is therapeutic, indicating that the client has been taking the medication as prescribed.
D. Hold the medication and assess for early manifestations of toxicity.
A lithium level of 1.0 mEq/L is within the therapeutic range and does not indicate toxicity. Holding the medication is not warranted in this case.
A nurse is reinforcing teaching with an older adult client who has major depressive disorder and a prescription for nortriptyline 25 mg daily. Which of the following client statements indicates understanding of the teaching?
A. "I should sit on the side of the bed before standing up in the morning.".
This statement demonstrates an understanding of orthostatic hypotension, a potential side effect of nortriptyline. Nortriptyline, a tricyclic antidepressant, can cause postural hypotension, which puts the client at risk for dizziness and falls when standing up suddenly. Sitting on the side of the bed before standing helps the client adjust to the change in position gradually, minimizing the risk of orthostatic hypotension.
B. "I should take my nortriptyline before breakfast.".
This statement is incorrect. Nortriptyline should be taken with food to minimize gastrointestinal side effects. Taking it before breakfast can lead to an empty stomach, increasing the likelihood of nausea or gastric irritation.
C. "I will avoid drinking caffeinated beverages.".
This statement is not directly related to the medication nortriptyline. Avoiding caffeinated beverages is important for clients taking selective serotonin reuptake inhibitors (SSRIs), but it is not a crucial consideration for nortriptyline.
D. "I can no longer eat pepperoni pizza.".
This statement is not relevant to the teaching about nortriptyline. Pepperoni pizza consumption is not directly linked to the medication's effects or interactions.
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?
A. Teach the client to use passive communication when interacting with others.
This choice is incorrect. Passive communication involves avoiding expressing one's needs, feelings, or opinions, which can hinder effective communication. Teaching a client with major depressive disorder to use passive communication is counterproductive, as assertive communication is more beneficial for their overall well-being.
B. Limit the client's involvement in unit activities.
This choice is incorrect. Isolating the client by limiting their involvement in unit activities can exacerbate feelings of depression and loneliness. Encouraging engagement in appropriate unit activities can help improve mood and social interactions.
C. Determine the client's need for assistance with grooming.
This choice is incorrect. While determining the client's need for assistance with grooming is a part of care planning, it is not the most appropriate action for a client with major depressive disorder. The question doesn't provide enough context to determine why grooming assistance is highlighted.
D. Ask the client to create her own schedule of daily activities.
This is the correct choice. Allowing the client to create their own schedule of daily activities empowers them to take an active role in their recovery. It can help restore a sense of control and structure in their life, which is particularly important for individuals with major depressive disorder.