If a client is experiencing moderate anxiety, a nurse will ...

[ap345]

If a client is experiencing moderate anxiety, a nurse will observe which of the following clinical manifestations? Select all that apply.
 
  A) The client can sustain attention on a particular focus.
  B) Verbally states, For some reason, I am feeling anxious now.
  C) Flights of ideas and confusion are noted.
  D) Because of inadequacy of observed data, they make distorted inferences.
  E) The client may pace, run, or fight violently if asked to perform a task they do not want to perform.

Question 2

A fellow nurse was confronted by the pharmacist about a medication error that was detected in the automated dispensing device.
 
  The medication administered to a client receiving palliative care may have caused an earlier death since the medication significantly decreases the client's respiratory rate when given at the administered dose. Which of the following statements by the nurse displays the use of rationalization?
 
  A) Thank you for pointing this error out. I will fill out an incident report immediately.
  B) Please don't tell my supervisor. She will put me on probation if she knows this information.
  C) I didn't think I needed to disclose this error since the patient is going to die anyway.
  D) Are you sure I made this error? I can't recall this incident.

[Kaytorgator]

Answer to Question 1

Ans: A, B
With moderate anxiety, a client sees, hears, and grasps less than previously. The client can attend to more if directed to do so. They are able to sustain attention on a particular focus and are selectively inattentive to content outside the focal area. The client with moderate anxiety is usually able to state, I am anxious now. With severe anxiety, inferences drawn may be distorted because of the inadequacy of observed data. With panic, the client has feelings of unreality. flights of ideas or confusion, and fear. They often repeat details. Many relief behaviors are used automatically (without thought). The enormous energy produced by panic must be used and may be mobilized as rage. Panicked clients may pace, run, or fight violently.

Answer to Question 2

Ans: C
Rationalization is when one avoids anxiety by explaining an unacceptable or disappointing behavior or feeling in a logical, rationale way. Rationalization may protect self-esteem and self-concept. Suppression reduces anxiety by intentionally avoiding thinking about disturbing problems, wishes, feelings, or experiences. It is useful in many situations such as test-taking situations. Denial avoids feelings associated with recognizing a problem.