a nurse is assessing a client who appears to be experiencing moderate anxiety during questioning which symptom shouldnt the nurse expect
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A healthcare professional is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptom shouldn't the healthcare professional expect?

Correct answer: C

Rationale: Palpitations are not typically associated with moderate anxiety. Fidgeting, laughing inappropriately, and nail biting are common behavioral symptoms of heightened stress levels. Palpitations may be more indicative of physiological responses, such as increased heart rate, which can occur in severe anxiety or panic attacks. Other signs of severe anxiety include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.

2. In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select one that doesn't apply.

Correct answer: C

Rationale: The lack of resources in pediatric mental health leads to underserved populations, increased stress in the family unit, and premature termination of services. However, markedly increased funding does not align with the negative consequences of resource shortages; instead, it would be a potential solution to address the lack of resources and providers in pediatric mental health.

3. A nurse is caring for a client who has been diagnosed with schizoaffective disorder. The client states, 'I am the president of the United States.' Which of the following responses should the nurse make?

Correct answer: C

Rationale: The nurse should avoid challenging the client's delusions directly. Asking for more information can help the nurse understand the client's experience and build rapport.

4. When an individual's stress response is sustained over a long period of time, which physiological effect of the endocrine system should one anticipate?

Correct answer: A

Rationale: When stress is prolonged, the body reaches the stage of exhaustion in the general adaptation syndrome, where compensatory mechanisms fail, and diseases of adaptation may occur. One physiological effect includes a decreased immune response, leading to decreased resistance to disease. Therefore, the correct answer is A. Increased libido (choice B) is not a typical physiological effect related to prolonged stress. Decreased blood pressure (choice C) is not commonly associated with sustained stress. Increased inflammatory response (choice D) may occur in the short term due to stress, but over a prolonged period, the immune system's function weakens, leading to decreased resistance to disease.

5. A client is diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include in the care plan? Select one that does not apply.

Correct answer: A

Rationale: Interventions for a client with OCD should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Allowing the client to perform rituals is an essential part of managing OCD and should not be restricted in the initial stages of care. Setting limits on the time for rituals helps prevent excessive engagement in them. Encouraging the client to verbalize feelings promotes emotional expression and processing. Providing a structured schedule of activities helps establish routine and predictability, which can be beneficial for individuals with OCD.

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