Flashcards in Chapter 15 Deck (35):
1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?
a. Verify the patient’s learning style.
b. Lower the patient’s current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.
A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient’s anxiety level. Use of defense mechanisms does not apply.
2. A woman is 5’7”, 160 lbs, and wears a size 8 shoe. She says, “My feet are huge. I’ve asked three orthopedists to surgically reduce my feet.” This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
a. Social anxiety disorder
b. Body dysmorphic disorder
c. Separation anxiety disorder
d. Obsessive-compulsive disorder due to a medical condition
Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient’s feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual's symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.
3. A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be:
a. “What would you like me to do to help you?”
b. “Why do you suppose you are feeling anxious?”
c. “I’m not sure I understand. Give me an example.”
d. “You must get your feelings under control before we can continue.”
Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is non-therapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
4. A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to:
a. provide for the patient’s safety.
b. encourage clarification of feelings.
c. respect the patient’s personal space.
d. offer an outlet for the patient’s energy.
Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient’s energy can occur when the current panic level subsides. Respecting the patient’s personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.
5. A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?
a. Fear c. Self-care deficit
b. Risk for injury d. Disturbed thought processes
A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.
6. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of:
a. flooding. c. relaxation technique.
b. desensitization. d. cognitive restructuring.
Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.
7. A patient undergoing diagnostic tests says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
a. Displacement c. Projection
b. Regression d. Denial
Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one’s own unacceptable thoughts or feelings to another.
8. A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety?
a. Mild c. Severe
b. Moderate d. Panic
Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
9. A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?
a. Reassure the patient that all nurses are skilled in providing postoperative care.
b. Present the information again in a calm manner using simple language.
c. Tell the patient that staff is prepared to promote recovery.
d. Encourage the patient to express feelings to family.
Giving information in a calm, simple manner will help the patient grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the patient’s attention.
10. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?
a. Offering hope allays and defuses the patient’s anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving begin.
c. Anxiety is reduced by focusing on and validating what is occurring in the environment.
d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.
All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.
11. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?
a. “Have you been a victim of a crime or seen someone badly injured or killed?”
b. “Do you feel especially uncomfortable in social situations involving people?”
c. “Do you repeatedly do certain things over and over again?”
d. “Do you find it difficult to control your worrying?”
Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.
12. A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?
a. An interview room furnished with a desk and two chairs
b. A small, empty storage room with no windows or furniture
c. A room with an examining table, instrument cabinets, desk, and chair
d. The nurse’s office, furnished with chairs, files, magazines, and bookcases
Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse’s office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.
13. A person has minor physical injuries after an auto accident. The person is unable to focus and says, “I feel like something awful is going to happen.” This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person’s level of anxiety?
a. Mild c. Severe
b. Moderate d. Panic
The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.
14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, “The nurse manager had a headache the day I was interviewed.” Which defense mechanism is evident?
a. Introjection c. Projection
b. Conversion d. Splitting
Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.
15. A patient tells a nurse, “My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I can’t find a single flaw.” This patient is demonstrating:
a. denial. c. idealization.
b. projection. d. compensation.
Idealization is an unconscious process that occurs when the individual attributes exaggerated positive qualities to another. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.
16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to give as a prn anxiolytic?
a. buspirone (BuSpar) c. amitriptyline (Elavil)
b. lorazepam (Ativan) d. desipramine (Norpramin)
Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.
17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse’s response?
a. Altruism c. Intellectualization
b. Suppression d. Reaction formation
Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse’s reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.
18. A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of:
a. repression. c. identification.
b. devaluation. d. compensation.
Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.
19. A person speaking about a rival for a significant other’s affection says in an emotional, syrupy voice, “What a lovely person. That’s someone I simply adore.” The individual is demonstrating:
a. reaction formation. c. projection.
b. repression. d. denial.
Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.
20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?
a. Rationalization c. Introjection
b. Compensation d. Regression
Rationalization involves unconsciously making excuses for one’s behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.
21. A student says, “Before taking a test, I feel very alert and a little restless.” The nurse can correctly assess the student’s experience as:
a. culturally influenced. c. trait anxiety.
b. displacement. d. mild anxiety.
Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. See relationship to audience response question.
22. A student says, “Before taking a test, I feel very alert and a little restless.” Which nursing intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements.
d. Listen attentively, using silence in a therapeutic way.
Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.
23. A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism?
a. “I don’t know why I do mean things.”
b. “I have always had poor impulse control.”
c. “That person should not have provoked me.”
d. “I’m really a coward who is afraid of being hurt.”
Rationalization consists of justifying one’s unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.
24. A patient experiencing panic suddenly began running and shouting, “I’m going to explode!” Select the nurse’s best action.
a. Ask, “I’m not sure what you mean. Give me an example.”
b. Capture the patient in a basket-hold to increase feelings of control.
c. Tell the patient, “Stop running and take a deep breath. I will help you.”
d. Assemble several staff members and say, “We will take you to seclusion to help you regain control.”
Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient’s anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.
25. A person who has been unable to leave home for more than a week because of severe anxiety says, “I know it does not make sense, but I just can’t bring myself to leave my apartment alone.” Which nursing intervention is appropriate?
a. Help the person use online video calls to provide interaction with others.
b. Advise the person to accept the situation and use a companion.
c. Ask the person to explain why the fear is so disabling.
d. Teach the person to use positive self-talk techniques.
Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as “I can’t leave my apartment” with positive thoughts such as “I can control my anxiety.” This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.
26. A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?
a. “I check where my car keys are eight times.”
b. “My legs often feel weak and spastic.”
c. “I’m embarrassed to go out in public.”
d. “I keep reliving a car accident.”
Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating “My legs feel weak most of the time” is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder. See relationship to audience response question.
27. When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to:
a. report drowsiness.
b. eat a tyramine-free diet.
c. avoid alcoholic beverages.
d. adjust dose and frequency based on anxiety level.
Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.
28. The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia?
a. “I’m sure I will get over not wanting to leave home soon. It takes time.”
b. “Being afraid to go out seems ridiculous, but I can’t go out the door.”
c. “My family says they like it now that I stay home most of the time.”
d. “When I have a good incentive to go out, I can do it.”
Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
29. A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?
a. feelings of responsibility for the health of family members
b. approval-seeking behavior from friends and family
c. persistent thoughts about bacteria, germs, and dirt
d. needs to avoid interactions with others
Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior. See relationship to audience response question.
30. A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping?
a. Allow the patient to set a hand-washing schedule.
b. Encourage the patient to participate in social activities.
c. Encourage the patient to discuss hand-washing routines.
d. Focus on the patient’s symptoms rather than on the patient.
Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom. See relationship to audience response question.
31. For a patient experiencing panic, which nursing intervention should be implemented first?
a. Teach relaxation techniques.
b. Administer an anxiolytic medication.
c. Prepare to implement physical controls.
d. Provide calm, brief, directive communication.
Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.
1. A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? Select all that apply.
a. Use a calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.
ANS: A, B, E
The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns.
2. A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply.
a. Caution in use of machinery
b. Foods allowed on a tyramine-free diet
c. The importance of caffeine restriction
d. Avoidance of alcohol and other sedatives
e. Take the medication on an empty stomach
ANS: A, C, D
Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.
3. Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? Select all that apply.
a. “Are there certain social situations that cause you to feel especially uncomfortable?”
b. “Are there others in your family who must do things in a certain way to feel comfortable?”
c. “Have you been a victim of a crime or seen someone badly injured or killed?”
d. “Is it difficult to keep certain thoughts out of your awareness?”
e. “Do you do certain things over and over again?”
ANS: B, D, E
The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia. See relationship to audience response question.