A nurse notes that a new client displays restlessness, ...

[dollx]

A nurse notes that a new client displays restlessness, hypervigilance, rapid pulse, dilated pupils, rapid shallow breathing, decreased attention, and an inability to reason effectively. The nurse should document the level of anxiety as:
 
  1. Mild +1
  2. Moderate +2
  3. Severe +3
  4. Panic +4

Question 2

A young, married female client is attracted to a male nurse. The client falsely accuses the male nurse of sexual harassment. The nursing supervisor recognizes the defense mechanism of:
 
  1. Projection
  2. Splitting
  3. Suppression
  4. Displacement

[momtoalll]

Answer to Question 1

ANS: 3
The cognitive symptoms given in the scenario suggest severe anxiety. Options 1 and 2: In mild and moderate anxiety, thinking is not distorted. Option 4: In panic level anxiety, the client is even more disorganized.

Answer to Question 2

ANS: 1
Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario.