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

ATI RN

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?

A. Restlessness
B. Rapid heart rate
C. Sweating
D. Dry mouth

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. Why is the DSM-5 useful in the practice of psychiatric nursing?

A. It guides the nurse in making accurate and reliable medical diagnoses.
B. It represents progress toward a more holistic view of mind and body.
C. It provides a framework for interdisciplinary communication.
D. It provides a template for nursing care plans.

Correct answer: A

Rationale: The DSM-5 is a crucial tool in psychiatric nursing as it guides nurses in making accurate and reliable medical diagnoses of mental health conditions. Using the DSM-5 ensures that diagnoses are standardized, improving the quality and precision of care for clients. While the DSM-5 also supports a holistic view, interdisciplinary communication, and care plan development, its primary role in psychiatric nursing is to assist clinicians in diagnosing mental health conditions accurately.

3. Which is an example of the ego defense mechanism of regression?

A. A mother blames the teacher for her child's failure in school.
B. A teenager becomes hysterical after seeing a friend killed in a car accident.
C. A woman wants to marry a man exactly like her beloved father.
D. An adult throws a temper tantrum when he does not get his own way.

Correct answer: D

Rationale: The correct answer is D. Regression involves reverting to an earlier stage of development for comfort. In this case, an adult throwing a temper tantrum is regressing to a childlike behavior when faced with not getting their way, which is a form of seeking comfort associated with earlier development. Choices A, B, and C do not exemplify regression. Blaming the teacher, becoming hysterical after a traumatic event, or seeking a partner similar to a beloved father are not instances of reverting to earlier developmental stages to cope with stress or conflict.

4. A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse implement? Select one that does not apply.

A. Encourage participation in activities
B. Promote adequate nutrition and hydration
C. Monitor for suicidal ideation
D. Discourage verbalization of feelings

Correct answer: D

Rationale: Interventions for a client with bipolar disorder experiencing a depressive episode include encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discussing feelings is an essential part of therapy for clients with bipolar disorder, thus discouraging verbalization of feelings is not therapeutic and should not be implemented. Choice D is incorrect because it goes against the principles of therapeutic communication and emotional expression, which are crucial in managing bipolar disorder.

5. A patient is being educated about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health?

A. Mental health is the absence of any stressors.
B. Mental health is successful adaptation to stressors in the internal and external environment.
C. Mental health is incongruence between thoughts, feelings, and behavior.
D. Mental health is a diagnostic category in the DSM-5.

Correct answer: B

Rationale: The correct answer is B. Mental health is defined as the successful adaptation to stressors in the internal and external environment. This includes having thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms. Mental health is not solely the absence of stressors or incongruence between thoughts, feelings, and behavior, nor is it a specific diagnostic category in the DSM-5. Choice A is incorrect because mental health is not just the absence of stressors but the ability to adapt to them. Choice C is wrong as mental health involves congruence, not incongruence, between thoughts, feelings, and behaviors. Choice D is inaccurate as mental health is a broader concept than a specific diagnostic category in the DSM-5.