Anxiety--Lippincott
125. The nurse should warn a client who is taking a benzodiazepine about using which of the following medications in combination with his current medication? 1. Antacids. 2. Acetaminophen (Tylenol). 3. Vitamins. 4. Aspirin.
125. 1. Combining a benzodiazepine with an antacid impairs the absorption rate of the benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because no major drug interactions occur.
129. The client diagnosed with agoraphobia refuses to walk down the hall to the group room. Which of the following responses by the nurse is appropriate? 1. "I know you can do it." 2. "Try holding onto the wall as you walk." 3. "You can miss group this one time." 4. "I'll walk with you."
129. 4. The nurse should walk with the client to activate adaptive coping for the client experiencing high anxiety and decreased motivation and energy. Stating, "I know you can do it," "Try holding on to the wall," or "You can miss group this one time," maintains the client's avoidance, thus reinforcing the client's behavior, and does not help the client begin to cope with the problem.
131. A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which of the following statements by the nurse best deals with the client's feelings of "going crazy?" 1. "What do you mean when you say you think you're going crazy?" 2. "Most people feel that way occasionally." 3. "I don't know you well enough to judge your mental state." 4. "You sound perfectly sane to me."
131. 1. When the client says he thinks he is "going crazy," it is best for the nurse to ask him what "crazy" means to him. The nurse must have a clear idea of what the client means by his words and actions. Using an open-ended question facilitates client description to help the nurse assess his meaning. The other statements minimize and dismiss the client's concern and do not give him the opportunity to openly discuss his feelings, possibly leading to increased anxiety.
101. A 17-year-old female client who has been treated for an anxiety disorder since middle school with behavioral treatment and as-needed (PRN) anxiety medication is preparing to go to college. The parents are concerned that she will experience an exacerbation of symptoms if she attends college out of town and want the daughter to attend the local community college and live at home. The girl believes she can handle the challenge of leaving home for college. How should the nurse in the outpatient clinic respond to the family's concerns? 1. "Your parents have a point; transitions have been hard for you in the past." 2. "There are many pros and cons here that we all need to discuss together." 3. "Every high school graduate deserves the chance to take on new challenges." 4. "It may be premature for you to think of college at this point in time."
101. 2. The nurse cannot appear to take the side of either the student or her mother, so discussing the situation together where all points of view can be presented and evaluated is the best option. To avoid college altogether is likely to only escalate both parties' anxiety. CN: Psychosocial integrity; CL: Apply
102. A 16-year-old boy who is academically gifted is about to graduate from high school early since he has completed all courses needed to earn a diploma. Within the last 3 months he has begun to experience panic attacks that have forced him to leave classes early and to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? 1. "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled." 2. "You are putting too much pressure on yourself. You just need to relax more and things will be alright." 3. "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." 4. "It sounds like you have real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."
102. 4. The client's concerns are real and serious enough to warrant assessment by a physician rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome his anxiety, and in fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment is received. Just postponing college is likely to increase the client's anxiety rather than lower it since it does not address the panic he is experiencing. CN: Psychosocial integrity; CL: Analyze
103. A client has been diagnosed with post-traumatic stress disorder (PTSD) because he experienced childhood sexual abuse (CSA) by his babysitter and her boyfriend from ages 4 to 10. He is admitted for the second time after physically assaulting a woman he said was a prostitute. "She is no better than my babysitter and deserves to be dead. I'd like to kill the sitter too." With the knowledge of PTSD and CSA, which of the following nursing interventions should be implemented at admission? Select all that apply. 1. Institute precautions for suicide, assault, and escape. 2. Ask him to sign a no harm contract. 3. Provide safe outlets for his anger and rage. 4. Encourage him to express his attitude toward prostitutes during unit group sessions. 5. In one-to-one staff talks, encourage him to safely verbalize his anger toward his babysitter and her boyfriend.
103. 1, 2, 3, 5. Anger and rage could be directed at self and others. He implies that he did nothing wrong in assaulting the woman (denial) and may try to leave without treatment. A No Harm Contract is essential for everyone's safety. He needs safe outlets, including staff talks, for his anger. Talking about his views of prostitutes in unit groups may be upsetting to female clients who have sexual abuse issues as well, so this needs to occur in private. CN: Safety and infection control; CL: Create
104. A client is taking diazepam (Valium) for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. 1. To consult with his health care provider before he stops taking the drug. 2. To avoid eating cheese and other tyramine-rich foods. 3. To take the medication on an empty stomach. 4. Not to use alcohol while taking the drug. 5. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing.
104. 1, 4, 5. The nurse should instruct the client who is taking diazepam to take the medication as prescribed; stopping the medication suddenly can cause withdrawal symptoms. This medication is used for a short term only. The drug dose can be potentiated by alcohol and the client should not drink alcoholic beverages while taking this drug. Swelling of the lips and face and difficulty breathing are signs and symptoms of an allergic reaction. The client should stop taking the drug and seek medical assistance immediately. The client does not need to avoid eating foods containing tyramine; tyramine interacts with monoamine oxidase inhibitors, not Valium. The client can take the medication with food.
105. An adult client diagnosed with anxiety disorder becomes anxious when she touches fruits and vegetables. What should the nurse do? 1. Instruct the woman to avoid touching these foods. 2. Ask the woman why she becomes anxious in these situations. 3. Assist the woman to make a plan for her family to do the food shopping and preparation. 4. Teach the woman to use cognitive behavioral approaches to manage her anxiety.
105. 4. Cognitive behavioral therapy is effective in treating anxiety disorders. The nurse can assist the client in identifying the onset of the fear strategies to modify the behavior associated with the fears. Avoiding touching foods, asking about reasons for the anxiety, and providing ways to work around touching the foods do not deal with the anxiety and are not interventions that will help this client. CN: Psychosocial integrity; CL: Synthesizes that cause the anxiety and develop
106. A client who is pacing and wringing his hands states, "I just need to walk" when questioned by the nurse about what he is feeling. Which of the following responses by the nurse is most therapeutic? 1. "You need to sit down and relax." 2. "Are you feeling anxious?" 3. "Is something bothering you?" 4. "You must be experiencing a problem now."
106. 2. Asking, "Are you feeling anxious?" helps the client to specifically label the feeling as anxiety so that he can begin to understand and manage it. Some clients need assistance with identifying what they are feeling so they can recognize what is happening to them. Stating, "You need to sit down and relax," is not appropriate because the client needs to continue his pacing to feel better. Asking if something is bothering the client or saying that he must be experiencing a problem is vague and does not help the client identify his feelings as anxiety.
107. A client brought to the emergency department is perspiring profusely, breathing rapidly, and having dizziness and palpitations. Problems of a cardiovascular nature are ruled out, and the client's diagnosis is tentatively listed as a panic attack. After the symptoms pass, the client states, "I thought I was going to die." Which of the following responses by the nurse is best? 1. "It was very frightening for you." 2. "We would not have let you die." 3. "I would have felt the same way." 4. "But you're okay now."
107. 1. The nurse responds with the statement, "It was very frightening for you," to express empathy, thus acknowledging the client's discomfort and accepting his feelings. The nurse conveys respect and validates the client's self-worth. The other statements do not focus on the client's underlying feelings, convey active listening, or promote trust.
108. A client commonly jumps when spoken to and reports feeling uneasy. The client says, "It's as though something bad is going to happen." In which order from first to last should the following nursing actions be done? 1. Teach problem-solving strategies. 2. Ask the client to deep breathe for 2 minutes. 3. Discuss the client's feelings in more depth. 4. Reduce environmental stimuli.
108. 4. Reduce environmental stimuli. 2. Ask the client to deep breathe for 2 minutes. 3. Discuss the client's feelings in more depth. 1. Teach problem-solving strategies. Immediate anxiety-reducing strategies are to decrease stimuli and then do deep breathing. Once the anxiety is lessened, then the client's feelings can be explored for triggers and underlying issues. Then problem-solving strategies can be discussed to handle the triggers and issues appropriately.
109. Which of the following points should the nurse include when teaching a client about panic disorder? 1. Staying in the house will eliminate panic attacks. 2. Medication should be taken when symptoms start. 3. Symptoms of a panic attack are time limited and will abate. 4. Maintaining self-control will decrease symptoms of panic.
109. 3. It is important for the nurse to teach the client that the symptoms of a panic attack are time limited and will abate. This helps decrease the client's fear about what is occurring. Clients benefit from learning about their illness, what symptoms to expect, and the helpful use of medication. A simple biologic explanation of the disorder can convince clients to take their medication. Telling the client to stay in the house to eliminate panic attacks is not correct or helpful. Panic attacks can occur "out of the blue," and clients with panic disorder can become agoraphobic because of fear of having a panic attack where help is not available or escape is impossible. Medication should be taken on a scheduled basis to block the symptoms of panic before they start. Taking medication when symptoms start is not helpful. Telling the client to maintain self-control to decrease symptoms of panic is false the client cannot control when a panic attack will occur. CN: Psychosocial integrity; CL: Create information because the brain and biochemicals may account for its development. Therefore,
110. A client with panic disorder is taking alpra-zolam (Xanax) 1 mg PO three times daily. The nurse understands that this medication is effective in blocking the symptoms of panic because of its specific action on which of the following neurotransmitters? 1. Gamma-aminobutyrate. 2. Serotonin. 3. Dopamine. 4. Norepinephrine.
110. 1. Alprazolam, a benzodiazepine used on a short-term or temporary basis to treat symptoms of anxiety, increases gamma-aminobutyrate, a major inhibitory neurotransmitter. Because gamma-aminobutyric acid is increased and the reticular activating system is depressed, incoming stimuli are muted and the effects of anxiety are blocked. Alprazolam does not directly target serotonin, dopamine, or norepinephrine.
111. A client is diagnosed with generalized anxiety disorder (GAD) and given a prescription for venlafaxine (Effexor). Which of the following information should the nurse include in a teaching plan for this client? Select all that apply. 1. Various strategies for reducing anxiety. 2. The benefits and mechanisms of actions of Effexor in treating GAD. 3. How Effexor will eliminate his anxiety at home and work. 4. The management of the common side effects of Effexor. 5. Substituting adaptive coping strategies for maladaptive ones. 6. The positive effects of Effexor being evident in 4 to 5 days.
111. 1, 2, 4, 5. It is appropriate to provide education on medication mechanisms, benefits, and managing side effects. No medication will eliminate all anxiety, so teaching about anxiety reduction and adaptive coping is needed. Effexor is a serotonin-norepinephrine reuptake inhibitor antidepressant and it will take 2 to 4 weeks to feel the effects.
112. While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid? 1. Chocolate. 2. Cheese. 3. Alcohol. 4. Shellfish.
112. 3. Using alcohol or any central nervous system depressant while taking a benzodiazepine, such as alprazolam, is contraindicated because of additive depressant effects. Ingestion of chocolate, cheese, or shellfish is not problematic.
113. Which of the following statements by a client who has been taking buspirone (BuSpar) as prescribed for 2 days indicates the need for further teaching? 1. "This medication will help my tight, aching muscles." 2. "I may not feel better for 7 to 10 days." 3. "The drug does not cause physical dependence." 4. "I can take the medication with food."
113. 1. Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. BuSpar is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects not occurring for 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.
114. A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first? 1. Explain the effects of stress on the mind and body. 2. Reassure the client that her feelings are typical reactions to serious trauma. 3. Reassure the client that her symptoms are temporary. 4. Acknowledge the unfairness of the client's situation.
114. 2. The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.
115. After being discharged from the hospital with acute stress disorder, a client is referred to the outpatient clinic for follow-up. Which of the following is most important for the client to use for continued alleviation of anxiety? 1. Recognizing when she is feeling anxious. 2. Understanding reasons for her anxiety. 3. Using adaptive and palliative methods to reduce anxiety. 4. Describing the situations preceding her feelings of anxiety.
115. 3. The client with anxiety may be able to learn to recognize when she is feeling anxious, understand the reasons for her anxiety, and be able to describe situations that preceded her feelings of anxiety. However, she is likely to continue to experience symptoms unless she has also learned to use adaptive and palliative methods to reduce anxiety.
116. A client with acute stress disorder states to the nurse, "I keep having horrible nightmares about the car accident that killed my daughter. I shouldn't have taken her with me to the store." Which of the following responses by the nurse is most therapeutic? 1. "Don't keep torturing yourself with such horrible thoughts." 2. "Stop blaming yourself. It's only hurting you." 3. "Let's talk about something that is a bit more pleasant." 4. "The accident just happened and could not have been predicted."
116. 4. Saying, "The accident just happened and could not have been predicted," provides the client with an objective perception of the event instead of the client's perceived role. This type of statement reflects active listening and helps to reduce feelings of blame and guilt. Saying, "Don't keep torturing yourself," or "Stop blaming yourself," is inappropriate because it tells the client what to do, subsequently delaying the therapeutic process. The statement, "Let's talk about something that is a bit more pleasant," ignores the client's feelings and changes the subject. The client needs to verbalize feelings and decrease feelings of isolation.
117. The client, a veteran of the Vietnam war who has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which of the following responses by the nurse is appropriate? 1. "You did what you had to do at that time." 2. "Maybe you didn't kill as many people as you think." 3. "How many people did you kill?" 4. "War is a terrible thing."
117. 1. The nurse states, "You did what you had to do at that time," to help the client evaluate past behavior in the context of the trauma. Clients commonly feel guilty about past behaviors when viewing them in the context of current values. The other statements are inappropriate because they do not help the client to evaluate past behavior in the context of the trauma.
118. A client with acute stress disorder has avoided feelings of anger toward her rapist and cannot verbally express them. The nurse suggests which of the following activities to assist the client with expressing her feelings? 1. Working on a puzzle. 2. Writing in a journal. 3. Meditating. 4. Listening to music
118. 2. Writing in a journal can help the client safely express feelings, particularly anger, when the client cannot verbalize them. Safely externalizing anger by writing in a journal helps the client to maintain control over her feelings.
119. When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which of the following should the nurse initiate? 1. Helping the client to evaluate her sister's behavior. 2. Telling the client to avoid details of the accident. 3. Facilitating progressive review of the accident and its consequences. 4. Postponing discussion of the accident until the client brings it up.
119. 3. The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.
120. A soldier on his second tour of duty was notified of the date that he will be redeployed. As this date approaches, he is showing signs of excess anxiety and irritability and inability to sleep at night because of nightmares of IED (improvised explosive devices) tragedies, all leading to poor work performance. His commanding officer refers him to the base hospital for an evaluation. The admitting nurse should take the following actions in order of priority from first to last? 1. Remind him that any feelings and problems he is having are typical in his current situation. 2. Ask him to talk about his upsetting experiences. 3. Remove any weapons and dangerous items he has in his possession. 4. Acknowledge any injustices/unfairness related to his experiences and offer empathy and support.
120. 3. Remove any weapons and dangerous items he has in his possession. 1. Remind him that any feelings and problems he is having are typical in his current situation. 4. Acknowledge any injustices/unfairness related to his experiences and offer empathy and support. 2. Ask him to talk about his upsetting experiences. Safety is the first priority in clients experiencing Acute Stress Disorder (ASD). ASD symptoms are typical reactions to an abnormal situation that are not being handled effectively. When the client believes he is "normal," being accepted, understood, and supported, then he will be able to discuss his thoughts and feelings related to the traumas of the war.
121. A newly admitted 20-year-old client, diagnosed with posttraumatic stress disorder (PTSD), reluctantly reveals that she escaped from a satanic cult 2 years ago. The mother has been in the cult since the client was 3 years old and refused to leave with the client. The client says, "Nobody will ever believe the horrible things the men did to me, and my mother never stopped them." Which of the following responses is appropriate for the nurse to make? 1. "I'll believe anything you tell me. You can trust me." 2. "I can't understand why your mother didn't protect you. It's not right." 3. "Tell me about the cult. I didn't know there were any near here." 4. "It must be difficult to talk about what happened. I'm willing to listen."
121. 4. Survivors of trauma/torture have a lot of difficulty with trust and do not readily talk about the horrible events. Therefore, empathy and a willingness to listen without pressuring the client are crucial. Option 1 may or may not be possible and does not convey the empathy. It is sometimes difficult to believe what satanic cults can do to children. Option 2 diverts attention from the client to the mother. Option 3 shows more interest in the cult than the client.
122. A 15-year-old client diagnosed with post-traumatic stress disorder (PTSD) is admitted to the unit after slicing both arms with a razor blade. He says, "Maybe my mother will listen to me now. She tells me I'm just crazy when I say I'm screwed up because my stepdad had sex with me for years." The nurse should do the following in which order of priority first to last? 1. Ask the client about the stepdad possibly abusing younger children in the family. 2. Ask the client to be specific about what he means by "screwed up." 3. Ask the client to sign a No Harm Contract related to suicide and self-mutilation. 4. Ask the client to talk about appropriate ways to express anger toward his mother.
122. 3. Ask the client to sign a No Harm Contract related to suicide and self-mutilation. 1. Ask the client about the step-dad possibly abusing younger children in the family. 2. Ask the client to be specific about what he means by "screwed up." 4. Ask the client to talk about appropriate ways to express anger toward his mother. The nurse should first assure the client's safety after the client's self-mutilation. Another safety issue is whether the stepdad possibly may be abusing younger children; if so, a police report may need to be filed. Then, it is important to know what the client means exactly by "screwed up" to identify other emotions and behaviors that need attention. It is very common for survivors of childhood sexual abuse to have intense anger at those who did not stop or prevent the abuse, and once the other steps have been taken, the nurse can begin to help the client manage his anger.
123. A client diagnosed with posttraumatic stress disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which of the following suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. 1. Trying relaxation techniques to help decrease her anxiety before bedtime. 2. Taking the quetiapine (Seroquel) 25 mg as needed as prescribed by the primary health care provider. 3. Staying in the dayroom and trying to sleep in the recliner chair near staff. 4. Listening to calming music as she tries to fall asleep. 5. Processing the content of her flashbacks no less than an hour before bedtime. 6. Leaving her door slightly open to decrease noise during the nightly checks.
123. 1, 2, 4, 6. Relaxation techniques and listening to calming music decrease anxiety and promote sleep. Seroquel is often effective in decreasing nightmare and flashbacks and has a beneficial side effect of drowsiness. Leaving her door slightly open will decrease the noise of making 15-minute checks at night. Staying in the dayroom in a recliner with all the noise and lights is not likely to help. Processing memories an hour or two before bedtime doesn't allow enough time to calm down before sleep.
124. A client with posttraumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. The nurse interprets this action as which of the following? 1. A method of avoidance. 2. A detriment to progress. 3. The end of treatment. 4. A necessary break in treatment.
124. 4. The nurse judges the client's request for an interruption in treatment as a necessary break in treatment. A "time-out" is common and necessary to enable the client to focus on pressing problems and solutions. It is not necessarily a method of avoidance, a detriment to progress, or the end of treatment. A problem like housing can be very stressful and require all of the client's energy and attention, with none left for the emotional stress of treatment.
126. Which of the following client statements indicates the need for additional teaching about benzodiazepines? 1. "I can't drink alcohol while taking diazepam (Valium)." 2. "I can stop taking the drug anytime I want." 3. "Valium can make me drowsy, so I shouldn't drive for a while." 4. "Valium will help my tight muscles feel better."
126. 2. Valium, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided. Valium can cause drowsiness, and the client should be warned about driving until tolerance develops. Valium has muscle relaxant properties and will help tight, tense muscles feel better.
127. A client is diagnosed with agoraphobia without panic disorder. Which type of therapy is most effective for this illness? 1. Insight therapy. 2. Group therapy. 3. Behavior therapy. 4. Psychoanalysis.
127. 3. The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder.
128. The client diagnosed with a fear of eating in public places or in front of other people has finished eating lunch in the dining area in the nurse's presence. Which of the following statements by the nurse should reinforce the client's positive action? 1. "It wasn't so hard, now was it?" 2. "At supper, I hope to see you eat with a group of people." 3. "You must have been hungry today." 4. "It is progress for you to eat in the dining room with me."
128. 4. Saying, "It's a sign of progress to eat in the dining area with me," conveys positive reinforcement and gives the client hope and confidence, thus reinforcing the adaptive behavior. Stating, "It wasn't so hard, now was it," decreases the client's self-worth and minimizes his accomplishment. Stating, "At supper, I hope to see you eat with a group of people," will overwhelm the client and increase anxiety. Stating, "You must have been hungry today," ignores the client's positive behavior and shows the nurse's lack of understanding of the dynamics of the disorder.
130. A client diagnosed with obsessive-compulsive disorder has been taking sertraline (Zoloft) but would like to have more energy every day. At his monthly checkup, he reports that his massage therapist recommended he take St. John's wort to help his depression. The nurse should tell the client: 1. "St. John's wort is a harmless herb that might be helpful in this instance." 2. "Combining St. John's wort with the Zoloft can cause a serious reaction called serotonin syndrome." 3. "If you take St. John's, we'll have to decrease the dose of your Zoloft." 4. "St. John's wort isn't very effective for depression, but we can increase your Zoloft dose."
130. 2. The effectiveness of St. John's wort with depression is unconfirmed. The critical issue is that the combination of St. John's wort and Zoloft (a SSRI antidepressant) can produce serotonin syndrome, which can be fatal. The client should not take the St. John's wort while taking Zoloft.
132. A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing an effort to obtain which of the following? 1. Relief from anxiety. 2. Control of his thoughts. 3. Attention from others. 4. Safe expression of hostility.
132. 1. A client who is exhibiting compulsive behavior is attempting to control his anxiety. The compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an attempt to express hostility.
133. A client with obsessive-compulsive disorder, who was admitted early yesterday morning, must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed having breakfast yesterday with the other clients. Which of the following actions should the nurse institute to help the client be on time for breakfast? 1. Tell the client to make his bed one time only. 2. Wake the client an hour earlier to perform his ritual. 3. Insist that the client stop his activity when it's time for breakfast. 4. Advise the client to have breakfast first before making his bed.
133. 2. The nurse should wake the client an hour earlier to perform his ritual so that he can be on time for breakfast with the other clients. The nurse provides the client with time needed to perform rituals because the client needs to keep his anxiety in check. The nurse should never take away a ritual, because panic will ensue. The nurse should work with the client later to slowly set limits on the frequency of the action.
134. The nurse notices that a client diagnosed with major depression and social phobia must get up and move to another area when someone sits next to her. Which of the following actions by the nurse is appropriate? 1. Ignore the client's behavior. 2. Question the client about her avoidance of others. 3. Convey awareness of the client's anxiety about being around others. 4. Tell the other clients to follow the client when she moves away.
134. 3. The nurse conveys empathy and awareness of the client's need to reduce anxiety by showing acceptance and understanding to the client, thereby promoting trust. Ignoring the behavior, questioning the client about her avoidance of others, or telling other clients to follow her when she moves are not therapeutic or appropriate.
135. The nurse is developing a long-term care plan for an outpatient client diagnosed with dissociative identity disorder. Which of the following should be included in this plan? Select all that apply. 1. Learning how to manage feelings, especially anger and rage. 2. Joining several outpatient support groups that are process-oriented. 3. Identifying resources to call when there is a risk of suicide or self-mutilation. 4. Selecting a method for alter personalities to communicate with each other, such as journaling. 5. Trying different medicines to find one that eliminates the dissociative process. 6. Helping each alter accept the goal of sharing and integrating all their memories.
135. 1, 3, 4, 6. Managing suicidal thought, urges to self-mutilate, and the intense anger are critical safety issues. Then the focus can switch to communication methods for each alter and the integration issues. Process groups can be overwhelming when too much is revealed or when child alters are unable to understand the group content. There are no known medicines to stop the process of dissociating.
136. A comanager of a convenience store was taking the daily receipts to the bank when she was robbed at gunpoint. She did not report the robbery and could not be found for 2 days. In a city 100 miles away, a hotel manager called the police because the woman gave a false name and address. After learning that the robbery was confirmed by the bank cameras, she was admitted to the hospital with a diagnosis of dissociative fugue. The nurse should include which of the following in the client's care plan? Select all that apply. 1. Develop trust and rapport to provide safety and support. 2. Rule out possible physical and neurological causes for the fugue. 3. Help the client discuss what she can remember about the trip to the bank. 4. Seclude the client from the other clients because of her lack of memory. 5. Question her repeatedly about the robbery and how she responded. 6. Encourage the client to talk about her feelings about what has been happening.
136. 1, 2, 3, 6. A client experiencing a dissociate fugue needs to feel safe and supported as well as evaluated medically and neurologically. Then it is appropriate to discuss what she can remember about the trip to the bank and her feelings about all that has happened to her since then. It is not appropriate to seclude her from others or to apply pressure to get details about the crime at this time. The police and the bank will ask these questions during their investigations.
137. A client with a long history of experiencing dissociative identity disorder is admitted to the unit after the cuts on her legs were sutured in the Emergency Department. During the admission interview, the client tearfully states that she does not know what happened to her legs. Then a stronger, alter personality states that the client is useless, weak, and needs to be eliminated completely. The nurse should do which of the following first? 1. Explore the alter personalities' attitudes toward the client more thoroughly. 2. Place the client in restraints when the alter personality emerges. 3. Contract with the alter personality to tell the nurse when he has the urge to harm the client and the body they both share. 4. Keep the client in a stress-free environment so that the stronger alter personality does not get a chance to emerge.
137. 3. The No Harm Contract with any destructive alters is essential along with the reminder that the alters share the same body. Later, the alter's attitudes about the client can be explored in more depth. When alter personalities emerge, their behaviors are not predictable. Restraints could not be placed on the client soon enough. There are no behaviors to justify restraints at this point. Creating a stress-free environment is not possible.