A nurse is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptoms might the client demonstrate? Select all that apply.

Correct Answer: A

Rationale: In assessing a client experiencing moderate anxiety, the nurse should observe for manifestations that align with anxiety symptoms. Fidgeting is a common physical manifestation of anxiety and restlessness. In this scenario, the correct answer is A because fidgeting often accompanies anxiety as a way for the individual to release excess energy or nervousness. Laughing inappropriately (option B) can be a defense mechanism or a sign of disconnection from reality, typically seen in severe anxiety or other mental health conditions like schizophrenia, not moderate anxiety. Palpitations (option C) are more commonly associated with panic attacks or higher levels of anxiety rather than moderate anxiety, where physical symptoms may not be as pronounced. Nail biting (option D) can be a sign of nervousness, but it is not specific to anxiety and can also occur in various situations unrelated to anxiety. Educationally, understanding the specific manifestations of anxiety at different levels can help nurses accurately assess and intervene appropriately in mental health settings. Recognizing these symptoms aids in providing effective care and support for clients experiencing anxiety.

Correct Answer: A

Rationale: In interpersonal theory, a nurse should associate the underlying concept of the effects of social processes on personality development when assessing clients. This theory emphasizes how social interactions and relationships shape an individual's personal development and behavior. By understanding how these social processes influence a person's experiences and perceptions, a nurse can gain valuable insights into the client's needs and challenges. This, in turn, enables the nurse to provide more holistic and effective care tailored to the client's specific circumstances and interpersonal dynamics.

Correct Answer: C

Rationale: Initiative vs. Guilt: This stage occurs in early childhood (ages 3–6). Children begin to assert control and power over their environment through play and social interactions. Successfully resolving this stage leads to a sense of initiative and confidence in their abilities. The child’s desire to do tasks independently reflects this stage.Trust vs. Mistrust: This stage occurs during infancy (birth to 1 year). The focus is on developing trust when caregivers provide reliability and care.Autonomy vs. Shame and Doubt: This stage occurs during toddlerhood (ages 1–3). It involves developing a sense of personal control over physical skills and independence. Industry vs. Inferiority: This stage occurs in school-age children (ages 6–12). The focus is on developing a sense of competence through school and social activities.

Correct Answer: A

Rationale: According to Erikson's psychosocial development theory, the trust versus mistrust stage occurs during infancy (first year of life). This stage is focused on developing trust in caregivers and the world. If a person struggles with trust-related issues later in life, it may indicate a lack of successful resolution of the trust versus mistrust stage during infancy. In this scenario, the client's difficulty trusting people at age 29 suggests a stagnation or regression in development, specifically related to trust. This interpretation aligns with the idea that unresolved issues from earlier stages can impact functioning in later stages.

Correct Answer: A

Rationale: According to Peplau's Theory of Interpersonal Relations, the foundation of effective nursing care is the establishment of a therapeutic nurse-client relationship. This relationship is essential for addressing client symptoms because it provides a supportive and trusting environment for the client to open up, express their feelings, and work collaboratively with the nurse towards healing and resolution. By establishing a therapeutic relationship based on empathy, trust, and understanding, the nurse can better assess the client's needs, provide appropriate care, and assist the client in managing their symptoms effectively. This approach also enhances communication, promotes client engagement in their own care, and fosters a sense of empowerment and well-being.