The nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. The nurse suspects which of the following?
1. Stress reaction
2. Role confusion
3. Impending heart attack
4. Dysfunctional anxiety
1
Rationale 1: A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms.
Rationale 2: There are no data to support the concern of role confusion.
Rationale 3: Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate but there are other more classic symptoms that typically also appear.
Rationale 4: Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional.
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