a nurse is assessing a client who is experiencing severe anxiety which of the following symptoms should the nurse expect to observe
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Nursing Elites

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ATI Mental Health

1. A healthcare professional is assessing a client who is experiencing severe anxiety. Which of the following symptoms should the healthcare professional expect to observe?

Correct answer: B

Rationale: Rapid heart rate is a characteristic symptom of severe anxiety due to the body's fight-or-flight response being activated. This physiological response leads to an increased heart rate to prepare the body to deal with perceived threats. Healthcare professionals should be vigilant in monitoring and managing this symptom in clients experiencing severe anxiety.

2. A patient with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?

Correct answer: D

Rationale: The most appropriate nursing intervention when a patient with schizophrenia is experiencing auditory hallucinations is to ask the patient to describe the content of the hallucinations. This intervention helps assess the risk associated with the hallucinations and provides valuable insight into the patient's condition, aiding in developing an effective care plan. Encouraging the patient to ignore the voices (Choice A) may not address the underlying issues or risks associated with the hallucinations. Providing a structured and safe environment (Choice B) is important but does not directly address the hallucinations. Engaging the patient in a debate about the reality of the voices (Choice C) may worsen the situation by invalidating the patient's experiences.

3. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response?

Correct answer: B

Rationale: The correct answer is B: 'How you reacted to past experiences influences how you feel now.' This response is appropriate because past experiences can shape an individual's current response to stress. It acknowledges the impact of learned patterns and coping mechanisms on one's current adaptation to stressors. Choice A is incorrect because genetics can play a role in temperament to some extent. Choice C is incorrect because while physical health can contribute to stress management, it is not the sole determinant of stress levels. Choice D is incorrect as stress is not always avoidable, but coping mechanisms can help manage and reduce its impact.

4. The client recently survived a plane crash and is assessed by the nurse. Which client statement would cause the nurse to suspect that the client may be experiencing PTSD?

Correct answer: D

Rationale: Experiencing intrusive thoughts about a traumatic event, such as a plane crash, that occur unexpectedly and repeatedly is a common symptom of Post-Traumatic Stress Disorder (PTSD). These thoughts can be distressing and are often a key indicator of PTSD. Options A, B, and C demonstrate coping mechanisms and fears related to the traumatic event but do not specifically address the hallmark symptom of intrusive thoughts. Therefore, option D is the correct choice as it aligns with a potential symptom of PTSD.

5. A nursing instructor is teaching a group of students about intimate partner violence. Which response by the students indicates no further teaching is needed?

Correct answer: A

Rationale: The correct answer is A. Alaska Native women do report the highest rate of intimate partner violence. This statistic is important for healthcare professionals to be aware of to provide culturally sensitive care and interventions. Choices B, C, and D are incorrect statements. While it is essential to understand disparities in intimate partner violence rates among different populations, in this context, the focus is on recognizing the accurate information provided about Alaska Native women.

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