a nurse is assessing a client who has been diagnosed with generalized anxiety disorder which of the following findings should the nurse expect
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client has been diagnosed with generalized anxiety disorder. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Individuals with generalized anxiety disorder commonly exhibit symptoms like excessive worry, restlessness, and difficulty concentrating. Physical manifestations such as muscle tension and sleep disturbances are also prevalent. Shortness of breath and chest pain are more commonly associated with panic attacks rather than generalized anxiety disorder. Decreased appetite may be present in some cases, but excessive worry is a hallmark characteristic of generalized anxiety disorder.

2. A client diagnosed with OCD spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

Correct answer: D

Rationale: Intellectualization is a defense mechanism where an individual focuses on rational, logical explanations to distance themselves from uncomfortable emotions. In this scenario, the client discusses the OCD rituals in a detailed and analytical manner, avoiding the emotional aspects associated with them. This behavior reflects intellectualization rather than dissociation, rationalization, or sublimation. Dissociation involves a disconnection from reality, rationalization is the attempt to justify behaviors, and sublimation is redirecting unacceptable impulses into socially acceptable activities.

3. Which of the following is not a common side effect of selective serotonin reuptake inhibitors (SSRIs)?

Correct answer: C

Rationale: Common side effects of SSRIs include nausea, insomnia, weight gain, and sexual dysfunction. Weight loss is not a common side effect associated with SSRIs; instead, weight gain is more frequently observed. Therefore, the correct answer is C.

4. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

Correct answer: D

Rationale: When caring for a client with schizophrenia experiencing delusions, the nurse should present reality and offer reassurance without reinforcing the client's delusions. This approach helps the client maintain a connection to reality while feeling supported. Agreeing with the delusions may perpetuate false beliefs, while directly challenging them can lead to increased distress for the client. Encouraging the client to discuss their delusions in detail may further exacerbate their symptoms or reinforce their false beliefs. Therefore, the most therapeutic intervention is to gently present reality and provide reassurance to the client.

5. After a client with major depressive disorder undergoes electroconvulsive therapy (ECT), which of the following is a priority assessment for the nurse?

Correct answer: B

Rationale: The priority assessment for the nurse after a client undergoes electroconvulsive therapy (ECT) is monitoring for signs of respiratory distress. This is crucial due to the potential risk of complications from anesthesia, such as airway compromise or respiratory depression. Prompt identification and intervention in case of respiratory distress are essential to ensure the client's safety and well-being. Monitoring for signs of infection (Choice A) is important but not the priority immediately post-ECT. Hypotension (Choice C) and bleeding (Choice D) are also potential concerns but assessing respiratory distress takes precedence due to the immediate risk it poses to the client's well-being.

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