Anxiety

The nurse is working with a client who is suspected of having posttraumatic stress disorder after witnessing a violent crime. What statement by the client's spouse would suggest that the client is experiencing hyperarousal?

"My spouse always seems so irritated now, which isn't like my spouse."

A 25-year-old pregnant mother of two children under age 6 is very protective and will not allow her children to play outdoors for fear of tick bites. She is worn out from cleaning the house from top to bottom every day. She asks the nurse how she can stop worrying so much. What is the most appropriate response for the nurse? "Have you considered spraying your children with an insect repellent?" "Tell me your concerns about the children playing in your backyard." "Why do you worry about the children getting tick bites?" "Have you sprayed your backyard for ticks or other pests?"

"Tell me your concerns about the children playing in your backyard."

A person tells the nurse, "my wife is completely obsessed with keeping our house sterile." When inquiring about potential indicators of OCD, the nurse should prioritize what assessment question?

"how did her cleaning routines affect her quality-of-life?"

Four levels of Anxiety

1. Mild 2. Moderate 3. Severe 4. Panic

Panic attacks usually peak in about _______ minutes but can last as long as ______ minutes before normal functioning returns.

10 30

Anxiety is a biological mechanism that protects us with ______________ and _________ reactions, and the motivation of _____________ ________________.

Anxiety is a biological mechanism that protects us with physical and cognitive reactions, and the motivation of coping strategies. These responses include the fight or flight and sharpened cognitive processes.

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

Assess the client for signs and symptoms associated with post-traumatic stress disorder

Which of the following is a behavioral symptom of anxiety? Tremors Apprehension Avoidance Impatience

Avoidance

A client with diagnosis of OCD has been admitted to a psychiatric unit prior to undergoing psycho surgery. The nurse who is caring for the client should understand that:

Behavioral therapy and drug treatment have failed

Which medication classifications used in the treatment of panic disorder can cause physical dependence? Benzodiazepines Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants (TCAs) Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Benzodiazepines

Which of the following is true? a. Anxiety disorders are rare among children b. Individuals with generalized anxiety disorder usually have no prodromal symptoms c. A person suffering a panic attack may seek medical attention for the physical symptoms d. A phobia is a rational fear of dangerous objects or situations accompanied by avoidant behavior

C

Coping strategies are the actions we take to resolve the _________. They can be _______ or __________.

Coping strategies are the actions we take to resolve the threat. They can be conscious (planned) or unconscious (like a reflex).

Which medication would a nurse least likely expect to administer to a patient diagnosed with panic disorder? A. Fluoxetine B. Sertraline C. Imipramine D. Buspirone

D The rest are all antidepressants used for panic disorder Buspirone is antianxiety

thoughts or behaviors that people unconsciously use to respond to and cope with difficult situations, emotional conflicts, and external stressors—including anxiety. also called coping styles. can be helpful in dealing with problems...but can be problematic when overused.

Defense mechanisms

A client with posttraumatic stress disorder (PTSD) tells the nurse that he often feels like he has left his body and is looking at things from a distance. The nurse interprets this as:

Dissociation

A client diagnosed with panic disorder has been receiving medication therapy, which is being discontinued. The nurse should be alert for possible withdrawal symptoms if the client was receiving what?

Escitalopram (benzo)

A nurse is providing care to a client with a specific phobia. When developing their plan of care, which type of therapy would the nurse most likely expect to include in the treatment of choice? Implosive therapy Exposure therapy Systematic desentization Flooding

Exposure therapy

True or False? Panic is considered abnormal regardless of the situation and degree of threat.

False! Normal until no threat

Fear versus Anxiety

Fear is the emotional response to real or perceived imminent threat. Anxiety is the anticipation of future threat.

DSM-5 Criteria A. Excessive anxiety and worry about a number of events or activities (such as work or school performance), occurring more days than not, for at least 6 months B. The individual finds it difficult to control the worry C. The anxiety and worry are associated with three or more of the following: 1.Restlessness 2.Easily fatigued 3.Difficulty concentrating or the mind going blank 4.Irritability 5.Muscle tension 6.Sleep disturbance D. The anxiety or worry causes significant distress and/or disability E. The anxiety or worry is not due to the effects of a substance or a general medical condition F. The anxiety or worry is not due to another psychiatric condition.

Generalized Anxiety Disorder

While conducting a class on anxiety and stress reduction, a nurse describes the symptoms of anxiety (including panic), informing the class that the physical symptoms of a panic attack can mimic what? Stroke Gastrointestinal flu Heart attack Appendicitis

Heart Attack

Panic attacks and panic disorder are related to a _________ rate of suicidal ideation and suicide attempts.

Higher

The nurse is preparing to administer the prescribed antidepressant to a client with obsessive compulsive disorder. in comparing the dosage used for OCD with that for depression, the nurse would expect to administer a dosage that is: lower titrated based on weight same higher

Higher

Concomitant use of antidepressants with monoamine oxidase inhibitors (MAOIs) can cause which life-threatening drug interaction? Risk of seizures Sedation Hypotensive crisis Hypertensive crisis

Hypertensive crisis

The nurse is assessing a client and finds two enlarged supraclavicular lymph nodes. The nurse asks the client how long these enlarged nodes have been there. The client states, "I can't remember. A long time I think. Do I have cancer?" The nurse is aware that that body responds to stress. Which is an immediate physiologic response to stress the nurse would expect to see in this client? Increased blood pressure Pupil constriction Vasodilation of peripheral blood vessels Decrease in blood glucose levels

Increased blood pressure An initial response to stress, as seen by the fight-or-flight response, is an increase in the client's heart rate and blood pressure. Vasoconstriction leads to the increase in blood pressure. Blood glucose levels increase, supplying more readily available energy, and pupils dilate.

What distinguishes anxiety as a symptom of a disorder?

Intensity of the anxiety related to the situation Trigger for the anxiety Symptom clusters that accompany the anxiety

A client receiving benzodiazepine therapy as treatment for panic disorder comes to the emergency department for evaluation. The nurse suspects the client is experiencing benzodiazepine withdrawal based on which of the following findings? Select all that apply. Hypersomnia Irritability Apprehension Agitation Sour taste

Irritability Apprehension Agitation

after teaching a client about possible side effects of benzodiazepines, the nurse determines that additional teaching is needed when the client identifies which of the following as a possible side effect of the drug? Metallic taste visual disturbances sedation dizziness

Metallic taste

During which type of anxiety does a person's perceptual field actually increase? Panic Moderate Severe Mild

Mild

•Broadened perceptual field increases ability to observe the environment •Learning is possible •Observed behavior: - Increased awareness and alertness - Able to recognize and label anxiety

Mild Anxiety

•Narrowed perceptual field; selective inattention •May not be aware of what is happening in the periphery, but attention can be directed to it •Observed behavior: - Can state: "I am anxious" - Sees, hears and grasps less, but is able to sustain attention on one thing

Moderate Anxiety

Two separate disorders from anxiety in their own groups

Obsessive compulsive disorder Trauma and Stressor Related Disorders - PTSD

•Also called terror, horror, dread •Perceptual field focused on minute detail •Can be distorted and exaggerated or on scattered details in rapid succession •Felt by the person as an enormous threat to survival •Learning is impossible •Observed behavior: - Lots of disorganized behaviors - Rapid talking - Self absorbed - Feelings of unreality and comments to match

Panic Anxiety

DSM-5 Criteria •An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, during which time four or more of these occur: •Palpitations, pounding heart, or tachycardia •Sweating •Trembling or shaking •Sensations of shortness of breath or smothering •Feelings of choking •Chest pain or discomfort •Nausea or abdominal distress •Feeling dizzy, unsteady, or lightheaded •Chills or heat sensations •Paresthesias (numbness or tingling sensations) •Derealization (feelings of unreality) or depersonalization (feeling of being detached from self) •Fear of losing control or "going crazy" •Fear of dying

Panic Attack Symtpoms

DSM-5 Criteria A. Recurrent unexpected panic attacks B. At least one of the attacks has been followed by 1 or more of the following: 1.Persistent concern or worry about additional panic attacks or their consequences (losing control, having a heart attack) 2.Significant change in behavior related to the attacks (behavior intended to avoid having panic attacks) C. Not due to substance use or medical illness D. Not due to another mental disorder

Panic Disorder

A client is prescribed medication therapy as a treatment for panic disorder. Which medication would a nurse expect to administer when prescribed as a first-line medication therapy for panic disorder?

Paroxetine

DSM-5 Criteria A. Significant fear or anxiety about a specific object or situation B. The object or situation almost always provokes immediate fear or anxiety C. The object or situation is actively avoided or only endured with intense fear or anxiety D. The fear or anxiety is out of proportion to the actual danger posed by the object or situation E. The fear, anxiety, or avoidance persists for at least 6 months F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social or occupational functioning G. The fear, anxiety, or avoidance is not better explained by another physical or psychiatric condition

Phobic Disorder

A client has just adopted a child whose traumatic history resulted in a diagnosis of reactive attachment disorder. What nursing action best addresses this child's diagnosis?

Planning activities where the client and the child can bond

When developing a plan of care for a client diagnosed with panic disorder, which nursing diagnosis would be considered the priority? Anxiety Social Isolation Powerlessness Risk for self-directed violence

Risk for self-directed violence

Which medication classification has been used to treat social phobia? Selective serotonin reuptake inhibitors (SSRIs) Monoamine oxidase inhibitors (MAOIs) Tricyclic antidepressants (TCAs) Nonbenzodiazepines

Selective serotonin reuptake inhibitors (SSRIs)

According to psychodynamic theorists, anxiety develops from which of the following? Separation and loss Learned response Exposure to panicogenic substances Interoceptive conditioning

Separation and loss

•Perceptual field is greatly reduced •Very limited ability to focus outside of specific focus even when directed to do so •Observed behavior: - Perceptions greatly diminished - Attention very focused - May make distorted inferences - Relief behaviors used

Severe Anxiety

The psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?

Teaching the child how to interact appropriately with strangers

A group of nursing students are reviewing signs and symptoms of anxiety. The students demonstrate a need for additional review when they identify what? Palpitations Extreme restlessness Motor excitement Tearfulness

Tearfulness

A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

The adolescent expresses intense guilt for the inability to save the sibling

The nurse's assessment of a child from a dysfunctional family background suggests that the child lacks resilience. What outcome should the nurse identify after performing appropriate interventions?

The child demonstrates that the child is empowered to solve life problems

The nurse is working with two children who have been apprehended from a neglectful and abusive home. Initial assessments reveal that one child is much more traumatized than the other, despite similarities in their circumstances. The nurse should consider what possible explanation for their differing responses?

The children have differing levels of resilience

A 79-year-old client was diagnosed with early onset OCD related to fear of infection. What characteristic of the clients earlier life may have constituted a subclinical symptom?

The client always lined up to get her seasonal influenza vaccine on the first day it was made available

The nurse is performing an assessment of a client who has OCD. When assessing the clients risk for suicide, the nurse should prioritize what assessment finding?

The client expresses that he feels "utterly hopeless" change his behavior

The nurse is reviewing the health record of a client who developed posttraumatic stress disorder (PTSD) following a spouse's cardiac arrest and death. The health record states that the client experienced derealization during the traumatic event. What assessment finding would substantiate this statement?

The client states that the client cannot remember what happened during and immediately after the event

A client with OCD has been taught thought stopping techniques. The nurse should recognize what potential but I felt this intervention?

The client will be able to take control of obsessions

A client who is being treated for posttraumatic stress disorder tells the nurse, "Sometimes it's like I can't feel anything—not happiness, not sadness, not fear. Nothing." How should the nurse best interpret the client's statement?

The client's emotional numbing is a protective mechanism

A clients family describes the client as being utterly debilitated by the severity of the clients compulsions and depression. During the clients next scheduled appointment with the psychiatrist, the nurse should encourage the client to discuss which intervention?

The possibility of electroconvulsive therapy ECT

A teenage girl has been diagnosed with OCD that manifest with excessive handwashing. The clients father is exasperated, stating, "the simplest solution would be to take away her access to soap and water." How should the nurse best interpret her father's suggestion?

This action would cause the client significant anxiety and disstress

A client is prescribed a serotonin-norepinephrine reuptake inhibitor. The nurse would identify that which of the following is most commonly prescribed? Venlafaxine Fluoxetine Paroxetine Duloxetine

Venlafaxine

The nurse is interviewing a client who has a history of OCD involving fears of contamination. The client is delivering a long and detailed monologue about the topics of emerging viruses and antibiotic resistance. What is the nurses best action?

allow the client to express her thoughts without interrupting

A client has recently been diagnosed with OCD. When performing an assessment of the client, the nurse would be most likely to identify what comorbid signs and symptoms?

anhedonia, insomnia and thoughts of hopelessness

uncomfortable feeling of apprehension or dread that occurs in response to interna; mental stimuli; it can result in physical, emotional, cognitive, and behavioral symptoms.

anxiety

The nurse has been working with a client who has OCD and the nurse is meeting the clients mother and father for the first time. During this interaction, the nurse should:

assess the parents willingness to assist with behavioral techniques the client has been taught

A male client with OCD is beginning educational sessions that will focus on cognitive restructuring. Which outcome shut the nurse identify one planning this intervention?

client will identify the inaccuracies in his thinking processes

The psychiatric mental health nurse is providing care for a client who has OCD. The nurse can best promote the clients recovery and enhance therapeutic rapport by:

disguising any surprises at the clients rituals and demonstrating empathy

A child is suspected of having OCD, which of the following would be the first step in assessing the child?

distinguishing between normal childhood rituals and worries and those that are pathologic

The psychiatric mental health nurse is planning the care of a client whose elaborate room entry and exit rituals have led to a diagnosis of OCD. What action by the nurse best address is possible psychodynamic aspects of the ideology?

exploring the characteristics of the clients defense mechanisms

Which is the most common obsession experience by a client diagnosed with OCD?

fear of contamination

A client with OCD performs elaborate rituals involved opening and closing doors and turning lights on and off before leaving your room. The client is scheduled to begin exposure and response prevention(ERP). What should the nurse teach the client about this intervention?

your therapist will help you leave a room without touching the lights and face the resulting anxiety

A client with OCD has been taking clomipramine 25 mg PO for the past week. At the current follow up appointment, the client states, "I'm so groggy I don't think I can keep going with these pills." What are appropriate assessment questions the nurse should ask? Select all that apply. Are you taking any over-the-counter sleep aids? Have you used any herbal remedies and starting clomipramine? Are you making sure to take it on an empty stomach? Have you been drinking any alcohol beverages since you started these pills? What time of day are you taking your pill?

have you been drinking any alcoholic beverages since you started these pills? Are you taking any over-the-counter sleep aids? What time of day are you taking your pill? Have you used any herbal remedies and starting clomipramine?

Common somatic symptoms of GAD

insomnia, muscle aches, pain, and gastrointestinal issues. Substance use/dependence is a real concern: alcohol, nicotine, marijuana (Self-medication)

Nursing Interventions for phobic disorder

•A therapeutic relationship is essential when working with someone experiencing phobic anxiety •It is very easy to become frustrated with a person with a phobia. Use self-awareness to monitor for this in order to maintain your effectiveness and preserve the relationship. •Expect to use rapid-acting benzodiazepines to treat acute anxiety prior to or during procedures.

a normal but extremely overwhelming level of anxiety often experienced when a person is placed in a real or perceived life-threatening situation

panic

a sudden period of intense fear that peaks rapidly and is accompanied by significant physical and psychological distress

panic attack

An irrational fear of an object, person, or situation that leads to avoidant behavior.

phobia

Because anxiety has both a physical and a cognitive response, anxiety management techniques work best when they combine...

physical and cognitive components

A client with a history of panic disorder tells the nurse, "when I feel anxious and panicky, I say to myself, 'I can handle these symptoms.'"The nurse interprets this statement as which of the following? Positive self-talk systematic desensitization distraction panic control treatment

positive self-talk

A client with OCD has obsessions related to the threat of contamination and compulsions of handwashing. In order to protect the clients skin integrity, the nurse should:

provide soap that has moisturizers in it

Phobias you will likely encounter in nursing

•Agoraphobia - Fear of open spaces, fear of being out in public •Algophobia - Fear of pain •Claustrophobia - Fear of enclosed spaces •Hematophobia - Fear of blood •Microphobia - Fear of germs

Nursing Interventions for GAD

•Assess coping strategies, including substance use •Assess depression and suicidal ideation •Teach anxiety recognition •Teach anxiety management strategies, especially long-term approaches •Teach healthy coping strategies •Teach benefits of regular exercise, balanced nutrition, time management •Medication teaching

A nurse is reading a journal article about panic disorder and biologic theories associated with it. The nurse demonstrates understanding of the information by identifying which substances as being associated with panic disorders? Select all that apply. GABA norepinephrine dopamine serotonin acetylcholine

serotonin norepinephrine GABA

a state of imbalance between the demands placed on an individual and their ability to meet those demands.

stress

An internal or external event that leads to the feelings of the stress response.

stressors

he psychiatric mental health nurse is preparing a presentation for a group of colleagues and anxiety disorders. As part of the presentation the nurse plans to discuss the concept of interoceptive conditioning. Which information with the nurse most likely include in this discussion? There is an association between physical symptoms and a panic attack. A recent loss in the initiating event that leads to a panic attack. A person links and adverse event with a previous neutral event. The person experiences of phobic avoidance of the event.

there is an association between physical symptoms and a panic attack.

Anxiety management techniques work best when...

they are repeatedly practiced when the client is not anxious

A client who experienced serious and repeated traumas has been diagnosed with dissociative identity disorder after being rescued from an abuser. Before caring for this client, the nurse should be prepared for:

wide variations in the personality that the client exhibits.

A client with a recent diagnosis of OCD is scheduled to begin pharmacotherapy. What health education is most relevant to the clients likely drug regimen?

you'll likely be giving pills that you will take once per day

Nursing Interventions for Anxiety

•Be aware of own level of anxiety •Remain calm. •Establish a trusting relationship •Protect and reassure the client •Structure the environment to eliminate stressors •Assessment of client's anxiety should be ongoing •Determine client's ability to recognize the presence of anxiety •Describe daily life routines including rest, nutrition, activities, sleep patterns to determine anxiety in general and in specific areas of functioning •Incorporate selected stress management techniques •Encourage exploration and incorporation of solutions for prevention or alleviation of anxiety •Assess the client's use of caffeine, nicotine, and other stimulants •Asses the client for signs of depression and suicidal ideation •Assist the client to identify stressors •Encourage the client to express feelings and explore sources of feelings. •Help the client to examine cognitive processes and encourage positive self-talk. •Assist the client to maintain hope and find meaning in life. •Support the client's use of effective coping mechanisms

Nursing Interventions for panic disorder

•Ensure safe environment and safety of the client •Maintain therapeutic relationship •Teaching: - Breathing control (hyperventilation is common) - Relaxation techniques (guided imagery) - Promote physical activity - Distraction - Reframing - Positive self-talk - Medication teaching if meds prescribed

Anxiety disorders differ from "normal" anxiety by being...

•Excessive or persisting beyond developmentally appropriate periods •Longer duration •Out of proportion to the trigger

Risk factors for panic disorder include

•Female •Low socioeconomic status •Widowed, separated, divorced •Family history •Substance abuse •Tobacco use •Severe stressors •Anxiety symptoms in childhood •Adverse childhood events

Treatment for Panic Disorder

•Individual Psychotherapy •Medications for Panic Disorder: •SSRIs (Prozac, Paxil, Zoloft, etc.) •SNRIs (Venlafaxine) •Benzodiazepines (Ativan, Xanax, Klonopin) (Benzodiazepines are for acute use only, not indicated for long-term use)

Considerations for phobic disorder

•Individuals with phobic disorders recognize that their phobias (fears of specific objects, activities, and situations) are irrational. •Contact with the feared stimuli, or the mere thought of the stimuli, causes immediate, severe anxiety. •Individuals with phobic disorders attempt to manage their anxiety by avoiding the feared stimuli. •Avoidance of the feared stimuli may drastically interfere with routine activities.

•Onset of generalized anxiety disorder (GAD) is __________ •Many people with GAD call themselves ____________ •People with GAD may have _________ depressive symptoms.

•Onset of generalized anxiety disorder (GAD) is slow and gradual. •Many people with GAD call themselves "chronic worriers." •People with GAD may have mild depressive symptoms.

types of anxiety disorders

•Panic Disorder •Generalized Anxiety Disorder •Phobias

Panic Disorder symptoms

•Physical symptoms: Respiratory rate, pulse, diaphoresis, N/V, chest pain, balance, paresthesias •Affective symptoms: Expression of fear and panic •Cognitive symptoms: Derealization and depersonalization; fear of dying, fear of losing control, fear of going crazy •Social symptoms: Withdrawal from/avoidance of social situations that are associated with panic attacks •Spiritual symptoms: Feeling guilt, feeling that the person is being punished.

Nursing assessment for panic disorder

•Sleep patterns (sleep disturbance is common) •Physical activity (regular exercise can help decrease frequency and intensity of panic attacks) •Suicide and self-harm assessment •Current level of anxiety, triggers for anxiety •Medication history. Assess for medications that could contribute to anxiety/panic (bronchodilators, oral contraceptives, thyroid medications stimulants, steroids, caffeine, cocaine, methamphetamine)

Nursing assessment questions for panic attack

•What were you doing when the panic attack occurred? •What did you experience before and during the panic attack? (physical symptoms, thoughts, and feelings) •When did you begin to feel this way? How long did it last? •Do you have an explanation for what caused you to think and feel that way? •Have you ever experienced something like this before? If so, what were the circumstances? •Has anyone in your family had panic attacks? •What do you do to stay safe when you have a panic attack?

Treatment for Phobic Disorder

•While benzos can help decrease episodic anxiety associated with the phobia, NO medications have been shown to e effective for treating phobic disorder. •Individual psychotherapy using exposure therapy is the treatment oh choice. However, this is time consuming and the person must be invested in treatment.

Treatment for GAD

•Work up for physical symptoms (Primary Care Provider) •Individual psychotherapy - Solution-Focused Therapy and Cognitive Behavioral Therapy are especially effective approaches •Medications for GAD: - SSRIs - SNRIs - Buspirone - good one! - Beta blockers - Hydroxyzine (Antihistamine with serotonergic action) - Benzodiazepines should NOT be used - addiction/tolerance