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A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
- A. Incoherent speech
- B. Irritability
- C. Insomnia
- D. Chest pain
Correct Answer: B
Rationale: Incoherent speech indicates severe anxiety. Irritability is a mild anxiety sign, with maintained function. Insomnia suggests chronic anxiety. Chest pain aligns with severe anxiety or panic.
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A nurse is caring for a group of older adult clients. Which of the following client findings indicates delirium?
- A. A client expresses dislike of orange juice after reporting earlier that it was a favorite juice.
- B. A client wants to know what type of poison the nurse placed in her medication.
- C. A client asks when family members will be arriving after visiting 1 hr earlier.
- D. A client requests extra blankets when the thermostat in the room indicates 80°F.
Correct Answer: C
Rationale: Changing preferences isn’t delirium-specific. Suspecting poison suggests delusion, not necessarily delirium. Confusion about recent events, like family visits, indicates delirium’s hallmark disorientation. Requesting blankets in a warm room may reflect sensory issues, not delirium directly.
An older adult is given the diagnosis of depression and is started on medication. Which group of medications would be appropriate for the depressed older adult?
- A. Selective serotonin reuptake inhibitors (SSRIs)
- B. Benzodiazepines
- C. Hypnotics
- D. Monoamine oxidase inhibitors
Correct Answer: A
Rationale: SSRIs are often the first-line treatment for depression in older adults due to their favorable side effect profile, including lower risk of sedation and falls compared to other options. Benzodiazepines are not typically used for depression as they treat anxiety and can increase the risk of falls and confusion in older adults. Hypnotics are used for sleep issues, not as antidepressants, and don’t address the core symptoms of depression. Monoamine oxidase inhibitors are effective but often reserved for cases where other treatments fail due to their dietary restrictions and potential for serious side effects.
A nurse is contributing to the plan of care for a client who has dementia. Which of the following actions should the nurse include in the plan of care?
- A. Use an overhead loudspeaker to announce events.
- B. Post a written schedule of daily activities.
- C. Allow the client to choose free-time activities
- D. Provide a consistent daily routine.
Correct Answer: D
Rationale: Using an overhead loudspeaker can be disorienting or frightening for clients with dementia due to their sensitivity to loud noises and potential for confusion. A written schedule may not be helpful if the client has difficulty reading or understanding due to cognitive decline, which is common in dementia. While allowing choices is generally good, it can be overwhelming for someone with dementia depending on their cognitive ability, potentially leading to frustration or anxiety. A consistent daily routine helps provide structure and predictability, which can reduce confusion and anxiety in clients with dementia by creating a stable environment they can rely on.
A hospitalized client sees snakes on the walls of the hospital room and becomes anxious. This is an example of which of the following?
- A. Hallucinations
- B. Delirium
- C. Delusion
- D. Psychosis
Correct Answer: A
Rationale: Hallucinations involve perceiving things that aren’t present, like seeing snakes, fitting the client’s experience. Delirium is a broader state of confusion that may include hallucinations but isn’t specific to this symptom alone. Delusions are false beliefs, not perceptions. Psychosis is a general term that can include hallucinations but isn’t as precise as the specific symptom described.
A nurse is caring for a client who has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?
- A. Tell the client you will remain with her.
- B. Take the client to a quiet room.
- C. Ask the client what precipitated this anxiety
- D. Offer the client a prescribed anxiety medication
Correct Answer: A
Rationale: Reassuring presence stabilizes the client emotionally, addressing immediate distress. A quiet room helps but follows reassurance. Asking about triggers is secondary to calming the client. Medication may be needed, but support comes first.