Saunder's NCLEX review- Mental health- Anxiety disorder

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1.Remain with the client. 2.Put the client in a quiet room. 3.Teach the client deep breathing. 4.Encourage the client to talk about his or her feelings and concerns.

.Remain with the client. Rationale: If left alone, the severely anxious client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? 1.Assess the client's vital signs. 2.Identify the client's activity during the pain. 3.Assess for signs related to a panic disorder. 4.Determine the client's use of relaxation techniques.

1.Assess the client's vital signs. Rationale: Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client? 1.Crush the tablets before taking them. 2.Mix the tablet uncrushed in apple sauce. 3.Purchase the liquid preparation with the next refill. 4.Call the primary health care provider for a change in medication.

1.Crush the tablets before taking them. Rationale: Buspirone may be administered without regard to meals, and the tablets may be crushed. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. This medication is not available in liquid form. It is premature to advise the client to call the primary health care provider (PHCP) for a change in medication without first trying alternative interventions.

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time? 1.Remaining with the client 2.Teaching the client deep-breathing techniques 3.Encouraging the client to talk about her feelings 4.Putting the client in a quiet room, away from other clients

1.Remaining with the client Rationale: A client with severe anxiety may feel abandoned and become overwhelmed if left alone. Placing the client in a quiet room is also indicated, but it is more important to stay with the client. The client may not feel comfortable being located a distance from other people. It is not realistic to teach the client deep breathing or relaxation until the anxiety decreases. Encouraging the client to share feelings would be appropriate after anxiety has decreased.

The nurse gathers data from the client who was prescribed buspirone hydrochloride 1 month ago. The nurse interprets that the medication is effective when the client reports an absence of which event? 1.Delusions 2.Severe anxiety 3.Alcohol cravings 4.Paranoid thoughts

2.Severe anxiety Rationale: Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression. It is not recommended for the treatment of thought disorders (delusions), drug or alcohol cravings, or schizophrenia (paranoid thoughts).

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? 1.The client will show the initial signs that coping methods are failing. 2.The client will employ new coping methods that will resolve the problem. 3.The client will experience severe anxiety as a result of failed coping methods. 4.The client will begin to implement coping methods that have been successful in the past.

2.The client will employ new coping methods that will resolve the problem. Rationale: In the first phase of the crisis response, the client implements usual coping methods to bring about relief from the problem and shows signs of anxiety when these methods are failing. The second phase of crisis response involves a redefining of the threat or implementation of new coping methods that can result in resolution of the problem. If resolution does not occur in the second phase, the client progresses to severe or panic levels of anxiety reflective of the third phase of the response.

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? 1.The object of the crisis 2.The client's physical condition 3.The client's coping mechanisms 4.The presence of support systems

2.The client's physical condition Rationale: The initial nursing assessment of a client in a crisis state is to evaluate the physical condition of the client, the potential for self-harm, and the potential for harm to others. Once this has been determined and appropriate interventions have been initiated, the nurse would then proceed with the mental health interview that involves the remaining options

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

2.The death of a loved one Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."This form of therapy provides a negative reinforcement when the stimulus is produced."

4."This form of therapy provides a negative reinforcement when the stimulus is produced." Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Headache and tachypnea 2.Hyperactivity and dyspnea 3.Muscle twitches and cyanosis 4.Lightheadedness and paresthesias

4.Lightheadedness and paresthesias Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.The client has acidotic blood. 2.The client is probably overreacting. 3.The client is fluid volume overloaded. 4.The client is probably hyperventilating.

4.The client is probably hyperventilating. Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided.

A client diagnosed with anxiety is starting therapy with lorazepam. Which factor in the client's history should prompt the nurse to consult with the primary health care provider before administering the medication? 1.Hypothyroidism 2.Diabetes mellitus 3.Narrow-angle glaucoma 4.Coronary artery disease

3.Narrow-angle glaucoma Rationale: Lorazepam is a benzodiazepine and is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow-angle glaucoma because these medications can further increase the intraocular pressure. It also is contraindicated in pregnancy and in women who are breast-feeding. None of the other options are relevant to the administration of lorazepam.

A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply. 1.Turn the client's favorite TV show on. 2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety. 4.Lean against the wall casually with arms crossed.

2.Ask the client to identify how he or she feels. 3.Help the client identify the cause of the anxiety. Rationale: If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, asking the client to identify what and how he or she feels and helping the client to identify the causes of the feelings increase the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease the anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? 1.Call the client's family to arrange for transportation. 2.Contact the client's primary health care provider (PHCP). 3.Attempt to persuade the client to stay "for only a few more days." 4.Tell the client that leaving would likely result in an involuntary commitment.

2.Contact the client's primary health care provider (PHCP). Rationale: In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and should be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and will not likely be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it should not be used as a threat with the client.

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client? 1.The medication is addicting. 2.Dizziness and nervousness may occur. 3.Tolerance can develop with this medication. 4.The medication can produce a sedating effect.

2.Dizziness and nervousness may occur. Rationale: Buspirone hydrochloride is an anxiolytic medication. Dizziness, nausea, headaches, nervousness, lightheadedness, and excitement, which generally are not major problems, are side effects. Buspirone hydrochloride is not addicting, tolerance does not develop, and it is not sedating.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

2.Identifying anxiety-producing situations Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

When planning the discharge of a client with chronic anxiety, which is the most appropriatemaintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

2.Identifying anxiety-producing situations Rationale: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1.Dementia 2.Panic disorder 3.Multiple personality disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

2.Panic disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder Rationale: Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder? 1.Put the client in a supine position. 2.Provide emotional support and reassurance. 3.Withhold all sedative or antianxiety medications. 4.Tell the client to breathe very deeply but more slowly.

2.Provide emotional support and reassurance. Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client should try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1.Paranoid thought process 2.Rapid heartbeat or anxiety 3.Alcohol withdrawal symptoms 4.Thought broadcasting or delusions

2.Rapid heartbeat or anxiety Rationale: Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety.

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? 1.Tearful, self-isolated 2.Affect bland, withdrawn 3.Fist clenched, pounding table, fearful 4.Temperature 98.4º F (36.8º C); respirations 18 breaths/min

3.Fist clenched, pounding table, fearful Rationale: Anxiety signs and symptoms may take a physical form and if abnormal should be addressed as a priority for the client. A temperature of 98.4º F and respirations 18 breaths/min are normal vital signs. Tearfulness, self-isolation, a bland affect, and a withdrawn state are abnormal findings but are commonly associated with anxiety. These findings are not life threatening, although they should be monitored. Fist clenched, pounding the table, and exhibiting fear indicate a possible threat to safety of the client or others.

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? 1.Believes the attacker is in the emergency department 2.Detached, requiring gentle probing to respond to questions 3.Is pacing while describing the situation using a rapid speech pattern 4.Talks about being "panic stricken" that something else "bad" will happen

3.Is pacing while describing the situation using a rapid speech pattern Rationale: The client who has severe anxiety has significant somatic complaints, ineffective functioning, loud or rapid speech, and purposeless activity. Option 1 describes fear and paranoia. Option 2 is characteristic of a withdrawn client or a client with depression. Option 4 describes a panic state. Panic is associated with a feeling of dread and terror and a sense of impending doom.

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas

3.Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

3.Remain with the client until the anxiety decreases. Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? 1.Restrict the daughter's socializing time with her friends. 2.Keep her daughter out of school until her anxiety is well managed. 3.Restrict the amount of chocolate and caffeine products in the home. 4.Consider taking time off from work to help her daughter learn to manage the anxiety.

3.Restrict the amount of chocolate and caffeine products in the home. Rationale: It is recommended that clients with anxiety disorder abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Restricting interactions with friends and keeping the daughter out of school are unreasonable and unhealthy approaches. It may not always be realistic to expect a family member to take time off from work.