Nclex: Anxiety Disorders

Which of the following drugs have been known to be effective in treating obsessive-compulsive disorder (OCD)?

"3. Fluvoxamine (Luvox) and clomipramine (Anafranil)

A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, the nurse should first:

"3. escort the client to a quiet area and suggest using a relaxation exercise that he's been taught.

A client who lost her home and dog in an earthquake tells the admitting nurse at the community health center that she finds it harder and harder to "feel anything." She says she can't concentrate on the simplest tasks, fears losing control, and thinks about the earthquake incessantly. She becomes extremely anxious whenever the earthquake is mentioned and must leave the room if people talk about it. The nurse suspects that she has:

"3. posttraumatic stress disorder (PTSD).

While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?

"4. Notify the physician upon arrival at the operating room.

While administering medications to a group of clients admitted with anxiety, a nurse hears someone call for help. The nurse should respond by:

"4. locking the medication cart and responding to the call for help.

A client, age 40, is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse comes to take her to surgery, she is tearfully finishing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic?

"In case anything goes wrong? What are your thoughts and feelings right now?"

During the client-teaching session, which instruction should the nurse give to a client receiving alprazolam (Xanax)?

"Inform the physician if you become pregnant or intend to do so."

Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his hands for 18 minutes, comb his hair 444 strokes, and switch the bathroom light on and off 44 times. What is the most appropriate goal of care for this client?

"Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.

A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive-compulsive disorder (OCD) is associated with:

"repetitive thoughts and recurring, irresistible impulses.

Which behavior would most likely be manifested in a young child experiencing the protest phase of separation anxiety? A) Inactivity B) Clings to parent C) Depressed, sad D) Regression to earlier behavior

*B) Clings to parent* Rationale: In the protest phase, the child aggressively responds to separation from parents A, C and D are characteristic of despair.

The nurse is caring for a Vietnam War veteran with a history of explosive anger, unemployment, and depression since being discharged from the service. The client reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response?

1. "Many people who have been in your situation experience similar emotions and behaviors."

During alprazolam (Xanax) therapy, the nurse should be alert for which dose-related adverse reaction?

1. Ataxia

To help a client who compulsively makes lists, meet the goal of improved self-esteem, the nurse should: 1. assist the client to identify and develop strengths. 2. encourage the use of as-needed antianxiety medication. 3. engage in power struggles to limit list making. 4. encourage behavior changes only when client states feeling ready.

Answer = 1 Rationale: Providing for successes in other areas of the client's life helps improve feelings of self-worth

When working with a client with post-traumatic stress disorder who has frequent flashbacks, as well as persistent symptoms of arousal, the least effective nursing intervention would be to 1. encourage repression of memories associated with the traumatic event 2. explain that physical symptoms are related to the psychological state 3. teach effective stress management techniques 4. discuss possible meanings of the event

Answer = 1 Rationale: The goal of treatment for PTSD is to come to terms with the event rather than suppress it.

The nurse plans health teaching for a client with generalized anxiety disorder who is taking lorazepam (Ativan). Which topic should be included? 1. tyramine-free diet 2. caffeine restriction 3. skin care to prevent breakdown 4. dietary restriction of tryptophan

Answer = 2 Rationale: Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam (Ativan). Daily caffeine intake should be reduced to the amount contained in one cup of coffee.

When a client asks what causes his panic attacks, the nurse responds that research shows evidence to support the theory that panic disorders have their etiology in: 1. faulty learning 2. traumatic events 3. genetic-biological factors 4. developmental fixations

Answer = 3 Rationale: Panic attacks can be caused by the chemical dysregulation in the brain, thus supporting a biological theory of etiology. There is a close genetic relationship with members of the same family experiencing panic attacks

A client has sought treatment for a specific phobia: fear of cats. The nurse in the anxiety disorders clinic has established the nursing diagnosis, Anxiety related to exposure to phobic object (cats). A realistic short-term goal for this client would be: within 10 days, client will 1. avoid feared object whenever possible. 2. face feared object unassisted. 3. state that feared object no longer produces feelings of dread associated with anxiety. 4. practice relaxation techniques and report less distress related to thoughts of the feared object.

Answer = 4 Rationale: When the client is able to relax in the presence of thoughts, or the phobic object, the client will begin to experience a sense of control over the phobia.

A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the plan of care?

Exercising the client's arms regularly

A 49-year-old painter who recently fractured his tibia worries about his finances because he can't work. To treat his anxiety, his physician prescribes buspirone (BuSpar), 5 mg by mouth three times per day. During buspirone therapy, the client should avoid which of the following drugs?

Monoamine oxidase (MAO) inhibitors

A client with obsessive-compulsive disorder tells the nurse that he must check the lock on his apartment door 25 times before leaving for an appointment. The nurse knows that this behavior represents the client's attempt to:

reduce anxiety.

A client comes to the emergency department while experiencing a panic attack. The nurse should respond to a client having a panic attack by:

staying with the client until the attack subsides

A client who has been diagnosed with a sexually transmitted disease (STD) asks that this information not be shared with her family members. Which of the following responses from the nurse would be appropriate?

" ""Your health information is confidential, and I can't talk to anyone about it without your permission.""

(SELECT ALL THAT APPLY) After being examined by the forensic nurse in the emergency department, a rape victim is prepared for discharge. Due to the nature of the attack, this client is at risk for posttraumatic stress disorder (PTSD). Which symptoms are associated with PTSD?

" 1. Recurrent, intrusive recollections or nightmares 3. Sleep disturbances 6. Difficulty concentrating "

(SELECT ALL THAT APPLY) A physician prescribes clomipramine (Anafranil) for a client diagnosed with obsessive-compulsive disorder (OCD). What instructions should the nurse include when teaching the client about this medication?

"1. Avoid hazardous activities that require alertness or good coordination until adverse central nervous system (CNS) effects are known. 2. Avoid alcohol and other depressants. 3. Use saliva substitutes or sugarless candy or gum to relieve dry mouth. "

A nurse on the psychiatric unit realizes that she typically fails to administer medications according to schedule. What's the best way for the nurse to improve her medication administration practice?

"2. Evaluate her current practice and devise an improvement plan.

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time?

"3. Risk for injury

Which nursing intervention would be most helpful for a client experiencing a panic attack?

"3. Staying with the client and remaining calm, confident, and reassuring

A 59-year-old client is scheduled for cardiac catheterization the next morning. His physician prescribed secobarbital sodium (Seconal), 100 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that:

"4. sedatives reduce excitement; hypnotics induce sleep.

The physician orders a new medication for a client with generalized anxiety disorder. During medication teaching, which statement or question by the nurse would be most appropriate?

"Do you have any concerns about taking the medication?"

The psychosexual conflicts of preschool children make them extremely vulnerable to: A) separation anxiety. B) loss of control. C) bodily injury and pain. D) loss of identity.

*(C) bodily injury and pain.* Rationale: Intrusive procedures, whether or not they are perceived as painful, are threatening to the preschool child because of the poorly developed concept of body integrity. Separation anxiety is a characteristic of infancy. Loss of control is a characteristic fear of school-age children. Loss of identity is a concern of adolescents because illnesses are conceptualized as the effect on the individual.

A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child's bath, he asks for mommy. The nurse's BEST reply is: A) "Mommy will be here after lunch." B) "Mommy always comes back to see you." C) "Your mommy told me yesterday that she would be here today about noon." D) "Mommy had to go home for a while, but she will be here today."

*A) "Mommy will be here after lunch."* Rationale: Since toddlers have a limited concept of time, the nurse should translate the mother's statement about being back around noon by linking the arrival time to a familiar activity that takes place at that time. B- Such statements do not give the child any information about when his mother will visit. C- Twelve noon is a meaningless concept for a toddler. D- Such statements do not give the child any information about when his mother will visit.

A client with a history of drug and alcohol abuse is concerned that the hospital will divulge her history to her employer without her knowledge. What response by the nurse would be appropriate?

1. "Your personal health information can't be disclosed to your employer without your permission."

During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The client is pale with his mouth wide open and eyebrows raised. What should the nurse do first?

1. Assist the client to breathe deeply into a paper bag

Because antianxiety agents such as lorazepam (Ativan) can potentiate the effects of other drugs, the nurse should incorporate which instruction in her teaching plan?

1. Avoid mixing antianxiety agents with alcohol or other central nervous system (CNS) depressants

(SELECT AL THAT APPLY) A 54-year-old client diagnosed with generalized anxiety disorder is admitted to the facility. Which therapeutic modalities are typically used to treat this disorder?

1. Biofeedback 2. Buspirone 3. Relaxtion technique

The nurse refers a client with severe anxiety to a psychiatrist for medication evaluation. The physician is most likely to prescribe which psychotropic drug regimen for this client?

1. Buspirone (BuSpar), 5 mg orally three times per day "

After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for this client?

1. Exploring the meaning of the traumatic event with the client

The nurse notices that a client with obsessive-compulsive disorder dresses and undresses numerous times each day. Which comment by the nurse would be therapeutic?

1. I saw you change clothes several times today. That must be very tiring.

A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. What typically occurs in reaction formation?

1. The client assumes an attitude that is the opposite of an impulse that the client harbors.

While in the facility, a client with obsessive-compulsive disorder saves all used medicine cups and paper cups and arranges them in elaborate sculptures in the room. At home, the client saves mail and magazines and makes elaborate paper sculptures from them. Which outcome would indicate successful treatment for this client?

1. The client throws away all disposable cups

Lorazepam (Ativan) is often given along with a neuroleptic agent, such as haloperidol (Haldol). What is the purpose of administering the drugs together?

1. To reduce anxiety and potentiate the sedative action of the neuroleptic

A client is admitted to the psychiatric unit with a diagnosis of conversion disorder. Since witnessing the beating of his wife at gunpoint, he has been unable to move his arms, complaining that they are paralyzed. When planning the client's care, the nurse should focus on:

1. helping the client identify and verbalize feelings about the incident.

A client with borderline personality disorder tells the nurse, "You're the only nurse who really understands me. The others are mean." The client then asks the nurse for an extra dose of antianxiety medication because of increased anxiety. How should the nurse respond?

2. ""I'll have to discuss your request with the team. Can we talk about how you're feeling right now?""

A physician's order states to administer lorazepam (Ativan), 20 mg by mouth twice per day, to treat anxiety. How should the nurse proceed?

2. Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose.

A client in a psychiatric facility is prescribed escitalopram (Lexapro) for anxiety. She tells the nurse that she has been having "weird dreams" and feelings of wanting to "end it all." What action should the nurse take?

2. Consult a pharmacist to see if these symptoms are adverse effects of the drug.

"After months of coaxing by her husband, a client comes to the mental health clinic. She reports that she suffers from an overwhelming fear of leaving her house. This overwhelming fear has caused the client to lose her job and is beginning to take a toll on her marriage. The physician diagnoses the client with agoraphobia. Which treatment options are effective in treating this disorder?

2. Desensitization 3. Alprazolam (Xanax) therapy 4. Paroxetine (Paxil) therapy

A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when assisting with development of the plan of care?

2. Giving the client adequate time to perform rituals

A client tells the nurse that she has an overwhelming fear of having a heart attack. This client is most likely suffering from which disorder?

2. Panic disorder

(SELECT ALL THAT APPLY) After receiving a referral from the occupational health nurse, a client comes to the mental health clinic with a suspected diagnosis of obsessive-compulsive disorder. The client explains that his compulsion to wash his hands is interfering with his job. Which interventions are appropriate when caring for a client with this disorder?

2. Support the use of appropriate defense mechanisms. 4. Explore the patterns leading to the compulsive behavior. 6. Encourage activities, such as listening to music."

A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. When planning care for this client, what is the nurse's overall goal?

2. To help the client function effectively in her environment

A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?

2. Voice her concerns about continuity of care with the charge nurse.

Initial interventions for the client with acute anxiety include:

2. encouraging the client to verbalize feelings and concerns.

A client with a conversion disorder reports blindness, and ophthalmologic examinations reveal that no physiologic disorder is causing progressive vision loss. The most likely source of this client's reported blindness is:

2. having been forced to watch a loved one's torture.

While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. To control the client's anxiety, the nurse caring for this client may expect the resident to prescribe:

2. lorazepam (Ativan).

A client with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobias include:

2. severe anxiety and fear.

A woman, age 18, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. The client asks the nurse, "Why has this happened to me?" What is the most appropriate response?

3. "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."

A client is undergoing treatment for an anxiety disorder. Such a disorder is considered chronic and generalized when excessive anxiety and worry about two or more life circumstances exist for at least:

3. 6 months

The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include:

3. staying with the client and speaking in short sentences.

During the admission data collection, a client with a panic disorder begins to hyperventilate and says, "I'm going to die if I don't get out of here right now!" What is the nurse's best response?

4. ""You're having a panic attack. I'll stay here with you

During a panic attack, a client hyperventilates, becomes unable to speak, and reports symptoms that mimic those of a heart attack. Which nursing intervention would be best?

4. Accompany the client to his room; remain there and provide instructions in short, simple statements.

Victims of sexual assault can experience posttraumatic stress reactions after the attack. Which of the following statements best describes symptoms associated with posttraumatic stress disorder (PTSD)?

4. Flashbacks, recurring dreams, and numbness

The care plan for a client with agoraphobia includes increasing self-esteem via cognitive restructuring. When the client tells the nurse, "I'm not smart enough to get that job," the nurse should say: 1. "It must be difficult to be in that position." 2. "You shouldn't demean your abilities." 3. "Let's think about what you just said." 4. "It seems to me that you're intelligent."

Answer = 3 Rationale: Cognitive restructuring requires the client to examine automatic negative thoughts and replace them with a more realistic evaluation of oneself and abilities

When the psychiatrist prescribes alprazolam (Xanax) for the acute anxiety experienced by a client with agoraphobia, health teaching should include instructions 1. about a tyramine-free diet 2. to adjust dose and frequency of based on level of anxiety 3. to avoid alcoholic beverages 4. to report drowsiness

Answer = 3 Rationale: Drinking alcohol or taking other anxiolytics along with prescribed benzodiazepines should be avoided due to potentiation of the depressant effects of both drugs. Drowsiness is an expected effect and should be reported only if excessive somnolence is experienced.

Which of the following is a criterion for assessing the anxiety level in a client with an anxiety disorder? 1. ability to be assertive 2. ability to determine appropriateness of own behavior 3. attention span and concentration 4. sleep pattern

Answer = 3 Rationale: The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate, severe, and panic-level anxiety. Anxiety level cannot be measured by assertiveness. Sleep patterns may be disrupted for other reasons.

Which piece of subjective data obtained during the nurse's psychiatric assessment of a client experiencing severe anxiety would indicate the possibility of posttraumatic stress disorder? 1. "I keep washing my hands over and over." 2. "My legs feel weak most of the time." 3. "I'm afraid to go out in public." 4. "I keep reliving the rape."

Answer = 4 Rationale: After a psychologically traumatic event, the person may re-experience the event via dreams or flashbacks.

When interviewing and planning care for a client with fear of public speaking, the nurse is aware that social phobias are often treatable using: 1. meditation 2. response prevention 3. modeling 4. beta blockers

Answer = 4 Rationale: Beta blockers are often effective in preventing symptoms of anxiety associated with social phobias.

For planning purposes, the nurse caring for a client with obsessive-compulsive disorder knows that an effective treatment for obsessive-compulsive disorder is: 1. analysis 2. group therapy 3. flooding 4. clomipramine

Answer = 4 Rationale: Clomipramine (Tricyclic Antidepressant) has been effective in reducing OCD behavior in a large number of people with this disorder. The other strategies have been less successful on their own.

The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?

"1. By designating times during which the client can focus on the behavior

The nurse in a psychiatric inpatient unit is caring for a client with obsessive-compulsive disorder. As part of the client's treatment, the psychiatrist orders lorazepam (Ativan), 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to:

"1. avoid caffeine.

A nurse notices that a client who came to the clinic for treatment of anxiety disorder has a strong body odor. What can the nurse do or say to help this client?

"2. Ask the client basic hygiene questions to determine how frequently he bathes.

The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits?

"2. Encouraging the use of relaxation exercises

The nurse is formulating a short-term goal for a client suffering from a severe obsessive-compulsive disorder (OCD). An appropriately stated short-term goal is that after 1 week, the client will:

"2. participate in a daily exercise group.

The nurse is discharging a young child from the hospital. The nurse should instruct the parents to look for which posthospital child behaviors? (Select all the apply.) A) Tendency to cling to parents B) Jealousy toward others C) Demands for parents' attention D) Anger toward parents E) New fears such as nightmares

*A) Tendency to cling to parents* *C) Demands for parents' attention* *E) New fears such as nightmares* Rationale: Young children's posthospital behaviors include: • They show initial aloofness toward parents; this may last from a few minutes (most common) to a few days. This is frequently followed by dependency behaviors: • Tendency to cling to parents • Demands for parents' attention • Vigorous opposition to any separation (e.g., staying at preschool or with a babysitter) Other negative behaviors include: • New fears (e.g., nightmares) • Resistance to going to bed, night waking • Withdrawal and shyness • Hyperactivity • Temper tantrums • Food peculiarities • Attachment to blanket or toy • Regression in newly learned skills (e.g., self-toileting) Posthospital behaviors for older children include: Negative behaviors: • Emotional coldness followed by intense, demanding dependence on parents • Anger toward parents • Jealousy toward others (e.g., siblings)

When admitting a child to the inpatient pediatric unit, the nurse should assess for which risk factors that can increase the child's stress level associated with hospitalization? (Select all the apply.) A) Mild temperament B) Lack of fit between parent and child C) Below-average intelligence D) Age E) Gender

*B) Lack of fit between parent and child* *C) Below-average intelligence* *D) Age* *E) Gender* Rationale: Risk factors for increased stress level of a child to illness or hospitalization: • "Difficult" temperament • Lack of fit between child and parent • Age (especially between 6 months and 5 years old) • Male gender • Below-average intelligence • Multiple and continuing stresses (e.g., frequent hospitalizations)

The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, O.K.?" The nurse should: A) start the IV line because allowing the child to manipulate the nurse is bad. B) start the IV line because unlimited procrastination results in heightened anxiety. C) postpone starting the IV line until the child is ready so that the child experiences a sense of control. D) postpone starting the IV line until the child is ready so the child's anxiety is reduced.

*B) start the IV line because unlimited procrastination results in heightened anxiety. * Rationale: The nurse should start the IV line, recognizing that the child is attempting to gain control. Intravenous antibiotics are a priority action for the nurse. A short delay may be possible to allow the child some choice, but a prolonged delay only serves to increase the anxiety. If the timing of the IV line start was not essential for the start of IV antibiotics, this might be acceptable. The child may never be ready. The anxiety is likely to increase with prolonged delay.

A 4-year-old child will be having cardiac surgery next week. The child's parents call the hospital, asking about how to prepare her for this. The nurse's BEST response is to inform the parents that: A) preparation at this age will only increase the child's stress. B) preparation needs to be at least 2 to 3 weeks before hospitalization. C) children who are prepared experience less fear and stress during hospitalization. D) children who are prepared experience overwhelming fear by the time hospitalization occurs.

*C) children who are prepared experience less fear and stress during hospitalization.* Rationale: Preparation will reduce stress by having the child incorporate the threat more slowly. For this age group 1 week of preparation is recommended. Preparing the child for the hospitalization will reduce the number of unknown elements. Tours, handling some of the equipment, or being told stories about what to expect will increase the familiarity with items. A reduction in fear is usually observed.

The most consistent indicator of pain in infants is: A) increased respirations. B) increased heart rate. C) squirming and jerking. D) facial expression of discomfort.

*D) facial expression of discomfort.* Rationale: This is the most consistent behavioral manifestation of pain in infants. A, B and C - responses vary, depending on infant and pain.

The nurse working in an outpatient surgery center for children should understand that: A) children's anxiety is minimal in such a center. B) waiting is not stressful for parents in such a center. C) accurate and complete discharge teaching is the responsibility of the surgeon. D) families need to be prepared for what to expect after discharge.

*D) families need to be prepared for what to expect after discharge.* Rationale: Although anxiety may be reduced because of the lack of an overnight stay, the child will still experience the stress associated with a medical procedure. The waiting period while the child is having the procedure is a very stressful time for families. Discharge teaching is a responsibility of both the surgeon and the nursing staff. Discharge instructions should be provided in both written and oral form. They need to include normal responses to the procedure and when to notify the practitioner if untoward reactions are occurring.

During a shift report, the nurse learns that she will be providing care for a client who's vulnerable to panic attacks. Treatment for panic attacks includes behavioral therapy, supportive psychotherapy, and medication such as

2. antianxiety drugs.

The nurse is collecting data on a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:

2. diarrhea

A client enters the crisis unit complaining of increased stress from her studies as a medical student. She states that she has been increasingly anxious for the past month. Her physician prescribes alprazolam (Xanax), 25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when given concomitantly with alprazolam?

3. Diphenhydramine (Benadryl)

A nurse observes a medical student walk into a client's room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene?

3. Explain to the client that she has the right to refuse to answer questions asked by the medical student.

A client admitted to the unit is visibly anxious. When collecting data on the client, the nurse would expect to see which cardiovascular effect produced by the sympathetic nervous system?

3. Increased heart rate

A client with obsessive-compulsive disorder and ritualistic behavior must brush the hair back from his forehead 15 times before carrying out any activity. The nurse notices that the client's hair is thinning and the skin on the forehead is irritated — possible effects of this ritual. When planning the client's care, the nurse should assign highest priority to:

3. setting consistent limits on the ritualistic behavior if it harms the client or others.

(SELECT ALL THAT APPLY) A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of Anxiety. The short-term goal identified is: The client will identify his physical, emotional, and behavioral responses to anxiety. Which nursing interventions will help the client achieve this goal?

4. Observe the client for overt signs of anxiety. 5. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. 6. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise.

While driving home from work, a nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. Which action would be appropriate for the nurse to take?

4. Phone the nurse caring for the client and inform her of the client's request.

The nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the compulsion. Based on this finding, the nurse should look for signs of:

4. increased anxiety.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?

Administering a sedative as prescribed

For the client whose nursing diagnosis is Powerlessness related to inability to control compulsive cleaning, the nurse recognizes that the client uses cleaning to: 1. temporarily reduce anxiety. 2. gain a feeling of superiority. 3. receive praise from friends and family. 4. ensure the health of household members

Answer = 1 Rationale: The primary gain achieved from the client's use of these rituals is anxiety relief. Unfortunately, the anxiety relief is short-lived and the client must repeat the ritual frequently.

The nurse caring for a client diagnosed with generalized anxiety disorder tells a preceptor, "I find myself feeling uncomfortable and anxious around this client. When he starts trembling, perspiring and pacing, I find myself with cold clammy hands and my pulse races. I start worrying whether I'll be able to help him stay in control." In such an interaction, the client will most likely experience 1. claustrophobia 2. increased anxiety 3. fatigue 4. improved self-esteem

Answer = 2 Rationale: Anxiety is transmissible. The client who tunes in to the nurse's anxiety usually experiences heightening of his/her own anxiety.

The nurse has a client who checks and rechecks her home in response to an obsessive thought that her house will burn down. The nurse and client explore the likelihood whether the house will actually burn. The client states there is little likelihood of this occurring. This is making use of: 1. desensitization 2. cognitive restructuring 3. relaxation technique 4. flooding

Answer = 2 Rationale: Cognitive restructuring involves the client testing automatic thoughts and drawing new conclusions through practice and training.

A client reveals that she becomes panic-stricken when she gets within visual range of a dog. The nurse can assess this behavior as being consistent with: 1. social phobia 2. simple phobia 3. agoraphobia 4. generalized anxiety disorder

Answer = 2 Rationale: Intense persistent fear of an object is a clinical manifestation of a specific (simple) phobia. Specific and simple are used interchangeably.

For the client with ritualistic handwashing whose goal is the use of more effective coping skills, the nurse should employ the intervention of: 1. allowing the client to set own handwashing schedule. 2. encouraging client participation in unit activities. 3. encouraging the client to discuss handwashing in all groups. 4. focusing on the client's symptoms rather than on the client.

Answer = 2 Rationale: Since clients with OCD become overly involved in rituals, it is necessary to promote involvement with other people and activities in order to improve coping. Daily activities prevent constant focus on anxiety and symptoms.

For the client with compulsive handwashing, which outcome criterion indicates that the goal of improved social interaction has been successfully met? The client 1. asks for anxiolytic medication at the first signs of anxiety. 2. spends more time talking to others in the community. 3. decreases the amount of time spent handwashing. 4. sleeps 7 to 8 hours nightly.

Answer = 2 Rationale: The behavior that indicates improved social interaction is spending more time interacting with others.

A client informs the nurse at the anxiety disorders clinic that he experiences palpitations, difficulty breathing, and a sense of overwhelming dread whenever he leaves his home. This problem began after he was assaulted and robbed on his way to work. He has been unable to go to his office for over a month. The client asks the nurse, "Don't you agree that not being able to go out is pretty awful?" The most therapeutic reply is: 1. "What do you mean by 'awful'?" 2. "You feel awful because you're afraid to leave home?" 3. "No, I don't think it's awful." 4. "I guess some people might say that being housebound is pretty strange."

Answer = 2 Rationale: The nurse will be able to validate the possibility that the client is dissatisfied with being unable to control symptoms. The nurse should neither agree nor disagree with the client. It is important for the client to clarify his/her own thinking.

For the nursing diagnosis, Powerlessness related to inability to prevent rape, an appropriate nursing intervention would be to: 1. help the client discuss how she could have prevented the rape. 2. assist the client to identify coping strategies related to feeling helpless about the rape. 3. reassure the client that she has no control over situations such as these. 4. tell the client that everyone reacts in the same way she did.

Answer = 2 Rationale: While the client may be reassured that she was not responsible for the event, to reduce feelings of powerlessness she should be encouraged to learn how to cope with her feelings.

The client in question #1 has elected to be voluntarily admitted to a private mental health unit in order to work intensively on his problem. He has refused to leave the unit for activities since the day of admission. An appropriate nursing intervention to include in the care plan is to: 1. encourage him to ask for a community pass. 2. ask another client to accompany him off the unit. 3. assist him to journal the challenges of leaving the unit. 4. point out the irrationality of his fear.

Answer = 3 Rationale: Assisting the client to identify specific problems related to the phobia can foster problem solving, especially when cognitive therapy is used.

A client tells the nurse that she wants her physician to prescribe diazepam (Valium) for anxiety reduction. The physician has prescribed buspirone (BuSpar). The nurse's reply should be based on the knowledge that buspirone 1. can be administered prn 2. does not predispose the client to blood disorders 3. is not habit-forming 4. is faster-acting

Answer = 3 Rationale: Buspirone is considered effective in long-term management of anxiety since it is not habit-forming. Since it is long-acting, it is not valuable as a PRN medication.

When the nurse diagnoses that a client is experiencing panic-level anxiety, an intervention that should be immediately implemented is to 1. teach relaxation techniques 2. place the client in four-point restraints 3. reduce stimuli 4. gather a show of force

Answer = 3 Rationale: Clients experiencing panic-level anxiety are unable to focus on reality, ruling out option 1. Although the client is completely disorganized, violence may not be imminent, ruling out options 2 and 4. Reducing stimuli is helpful since the client is unable to screen stimuli. A simplified environment reduces demands on the client and supports reintegration.

Which statement made by a client who washes his or her hands compulsively identifies the thinking typical of a client with obsessive-compulsive disorder? 1. "I know I'll get my hands clean eventually; it just takes time." 2. "I need a milder soap that won't damage my hands so much." 3. "I feel so much better when my hands are clean. I can do other things." 4. "I feel driven to wash my hands, although I don't like doing it."

Answer = 4 Rationale: The person who uses obsessive-compulsive rituals generally acknowledges that the ritualistic behavior is not constructive, and that he/she dislikes doing it.