Saunders
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 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.
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 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 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 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.
When planning the discharge of a client with chronic anxiety, 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 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, 4, 5 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.
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 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 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 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.
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 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.
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 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.
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 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 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 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.
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 Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.
