A nurse is caring for a client slated for a cardiac procedure in the morning. Which behavior exhibited by the client would indicate the client is experiencing severe anxiety?

Question

1. The client thinks the hospital is a prison and says the jailers have taken the client's clothes.
2. The client is reading today's newspaper and makes small talk about a current event.
3. The client cannot remember what has been taught about post-operative breathing.
4. The client keeps asking about blood clots despite the nurses repeated answers.

Answer 1

4
Rationale: During severe anxiety, people focus on small or scattered details. In this case, the client cannot organize the responses the nurse gives to attain a clear picture of the treatment risks. The client reading the newspaper is showing little or minimal anxiety by reading the newspaper and engaging in what is happening in the world. Moderate anxiety leads to selective inattention wherein the client may not remember what the nurse taught about post-operative breathing. During panic, the perceptual field is disrupted and the client may be disoriented and confused which may explain the reference to prison and jailers.