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

ATI RN

ATI Mental Health Proctored Exam 2019

1. When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?

Correct answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.

2. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?

Correct answer: A

Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.

3. A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition?

Correct answer: D

Rationale: The client's presentation of progressive memory changes, poor judgment, and attention deficits align with classic signs of Alzheimer's disease. Alzheimer's is a neurodegenerative disorder characterized by cognitive decline that significantly impacts daily functioning. While delirium and mania may present with cognitive changes, Alzheimer's is specifically associated with progressive memory loss and cognitive impairment over time.

4. A client has been diagnosed with major depressive disorder. Which is an appropriate short-term goal for the client?

Correct answer: A

Rationale: Setting a goal for the client to report a decrease in depressive symptoms is appropriate as it is specific, measurable, and achievable in the short term. Monitoring changes in depressive symptoms provides valuable feedback on the effectiveness of the treatment plan. While establishing a sleep routine, improving social interactions, and setting realistic goals for the future are important aspects of recovery, they are more suitable as intermediate or long-term goals. In the context of short-term goals, focusing on symptom reduction can provide immediate feedback on the client's progress and help adjust the treatment plan accordingly.

5. Which response by a 15-year-old demonstrates a common symptom observed in patients diagnosed with major depressive disorder?

Correct answer: D

Rationale: Sleep disturbances, such as early morning awakening, are common symptoms of major depressive disorder.

Similar Questions

A client diagnosed with panic disorder is receiving discharge teaching from a healthcare provider. Which statement by the client indicates an accurate understanding of the teaching?
A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?
A client is diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include in the care plan? Select one that does not apply.
Which is an example of the ego defense mechanism of regression?
Which therapeutic intervention is most effective for social anxiety disorder?

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