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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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 client with bipolar disorder is experiencing a depressive episode. Which intervention should the nurse implement to support the client's recovery?

Correct answer: C

Rationale: During a depressive episode in bipolar disorder, encouraging the client to set realistic goals for daily activities can be beneficial. Setting achievable goals can provide structure, a sense of accomplishment, and help in breaking tasks into manageable steps, which can support the client's recovery process. Options A and B, while important in managing bipolar disorder, may not directly address the client's depressive symptoms during this episode. Option D, encouraging the client to express feelings of sadness, is not as effective as setting achievable goals in providing structure and a sense of accomplishment during a depressive episode.

3. How should the nurse characterize the client's appraisal of the job loss stressor?

Correct answer: D

Rationale: The client's statement reflects a positive outlook on the job loss, viewing it as a challenge and an opportunity for personal growth. This perspective suggests that the client is resilient and adaptive, focusing on new possibilities rather than dwelling on the negative aspects of the situation. Choice D, 'Challenging,' is the correct characterization as it aligns with the client's positive appraisal. Choices A, 'Irrelevant,' B, 'Harm/loss,' and C, 'Threatening,' are incorrect as they do not capture the client's adaptive response to the stressor.

4. A healthcare professional is assessing a client who has been diagnosed with major depressive disorder. Which symptom should the healthcare professional expect to observe?

Correct answer: B

Rationale: Weight gain is a common symptom of major depressive disorder. Individuals with major depressive disorder often experience changes in appetite, leading to weight gain or loss. This symptom is related to disruptions in the individual's eating habits and metabolism, which are commonly associated with depression. Choices A, C, and D are incorrect because increased energy, increased appetite, and restlessness are not typical symptoms of major depressive disorder. In fact, individuals with depression often experience fatigue, changes in appetite, and feelings of restlessness or agitation.

5. A client has been prescribed diazepam (Valium) for the treatment of anxiety. Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: A

Rationale: The correct instruction is to avoid drinking alcohol while taking diazepam (Valium) as it can potentiate the sedative effects and increase the risk of side effects such as drowsiness and dizziness. Taking the medication with food may help reduce stomach upset, but avoiding alcohol is crucial to ensure safe and effective use of diazepam. Choice B is partially correct, as taking the medication with food can indeed help with stomach upset, but it is not as crucial as avoiding alcohol. Choice C is incorrect because abruptly stopping diazepam can lead to withdrawal symptoms and should only be done under medical supervision. Choice D is incorrect as doubling the dose is dangerous and should never be done without healthcare provider approval.

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