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A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism should the nurse assess the client is using? a. Denial b. Distancing c. Regression d. Suppression

b. Distancing Distancing is an unwillingness or inability to discuss events. The behaviors described are not associated with any of the other options.

The nurse notices that a client who had a tuberculin skin test yesterday is frequently inspecting and touching the injection site. Even though the client was instructed that the test would not be read until 48 hours later, the client has asked numerous questions about a positive reaction and even asks the nurse if the test results look like it might be positive. How should the nurse analyze this data? 1. The client has an inquisitive nature. 2. The client is anxious that the test results may be significant. 3. The client is demonstrating obsessive-compulsive tendencies. 4. The client wants to increase personal knowledge about tuberculin skin testing.

2. The client is anxious that the test results may be significant. Anxiety varies with an individual's perception, which in turn depends on a person's psychosocial makeup, education, degree of maturity, and life experiences. The nurse should know that anxiety is exhibited in many various forms. People can communicate their anxiety both verbally and nonverbally. The nurse needs to identify cues, interpret them, and seek to validate them. Options 1, 3, and 4 are unrelated to the information described in the question.

A client with depression is scheduled for an electroconvulsive therapy (ECT) treatment and says to the nurse, "I've seen this in a movie and I'm scared that it will hurt." Which therapeutic response should the nurse make to the client? a. "Tell me what you know about the procedure." b. "All clients undergoing ECT have the same fears." c. "You have a very serious psychiatric problem that can be helped by this procedure." d. "Don't be afraid. Your doctor has done this procedure hundreds of times and you needn't worry."

a. "Tell me what you know about the procedure." Varcarolis (2017), pp. 97-98, 218. Having the client explain what the client knows about the procedure is a therapeutic communication technique that explores the client's feelings and will establish a baseline for further teaching needs. Option 2 is a factual type of statement (correct or incorrect) and does not respond to the client's feelings. Option 3 does not address the client's fears, and the use of a very serious psychiatric problem may further alarm the client and escalate anxiety. Option 4 diminishes the client's feelings by directing attention away from the client and to the doctor's importance.

The nurse is reviewing the cases of selected clients with anxiety disorders. The nurse interprets that clients with which conditions are most likely to be treated with behavior therapy? Select all that apply. a. Agoraphobia b. Panic disorder c. Claustrophobia d. Post-traumatic stress disorder e. Obsessive-compulsive disorder

a. Agoraphobia b. Panic disorder c. Claustrophobia e. Obsessive-compulsive disorder Varcarolis (2017), pp. 23, 138-139.

The nurse implements which de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior? Select all that apply. a. Avoid verbal struggles. b. Provide clear options to the client. c. Use therapeutic touch on the client's shoulder. d. Maintain both the client's self-esteem and dignity. e. Establish what the client considers to be her or his needs. f. Use a firm and assertive tone of voice when speaking to the client.

a. Avoid verbal struggles. b. Provide clear options to the client. d. Maintain both the client's self-esteem and dignity. e. Establish what the client considers to be her or his needs. When the client is angry and exhibits increasingly agitated behavior, the nurse should employ de-escalation techniques to prevent client violence and assaultive behaviors. These techniques include assessing the situation, using a calm and clear tone of voice when communicating with the client, remaining calm, avoiding verbal struggles, presenting clear options to the client, and maintaining the client's self-esteem and dignity. The nurse should establish what the client considers to be her or his need and maintain a large personal space (touching the client could increase agitation).

The nurse is teaching a new nurse about anxiety disorders. The nurse notes that the new nurse needs further teaching if the new nurse states that which is a common concurrent disorder? a. Catatonia b. Eating disorders c. Substance abuse d. Depressive disorders

a. Catatonia Varcarolis (2017), pp. 142, 251. Anxiety disorders include panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and phobias. Anxiety disorders frequently co-occur with eating disorders, substance abuse, and depressive disorders; catatonia is not commonly associated with anxiety disorders.

A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse should initially allow the client to continue this behavior because it has what therapeutic effect for the client? a. Relieves the client's anxiety b. Decreases the chance of infection c. Gives the client a feeling of self-control d. Increases the client's sense of self-esteem

a. Relieves the client's anxiety Varcarolis (2013), p. 177. The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Options 2 and 3 are also incorrect interpretations of the client's need to perform this behavior. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.

A client comes into the emergency department demonstrating manifestations indicative of a severe state of anxiety. What is the priority nursing intervention at this time? a. Remaining with the client b. Placing the client in a quiet room c. Teaching the client deep-breathing exercises d. Encouraging the expression of feelings and concerns

a. Remaining with the client If the client is left alone with severe anxiety, the client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also indicated, but the nurse must stay with the client. It is not possible to teach the client deep-breathing or relaxation exercises until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.

The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond? a. "Do you want me to call your daughter?" b. "Can you tell me a little about what has you so upset?" c. "Try not to be so upset. Psychological stress is bad for your heart." d. "I understand how you feel. I'd cry, too, if I had a major heart attack."

b. "Can you tell me a little about what has you so upset?" Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.

A client is admitted to the mental health unit with a diagnosis of panic disorder. The nurse should check the primary health care provider's prescription sheet anticipating that which medication, a benzodiazepine, will be prescribed? a. Doxepin b. Alprazolam c. Imipramine d. Bupropion

b. Alprazolam Alprazolam, which is a benzodiazepine antianxiety agent, depresses the central nervous system (CNS) and induces relaxation in clients with panic disorders. The medications mentioned in the remaining options are classified as antidepressants, and they act by stimulating the CNS to elevate mood.

The nurse is teaching a client diagnosed with angina pectoris about home care measures and lifestyle changes. During the teaching session, the client continually changes the subject. The nurse determines which behavior is being demonstrated by the client? a. Anger b. Denial c. Anxiety d. Depression

b. Denial Denial is a defense mechanism that allows the client to minimize a threat and may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina pectoris, or myocardial infarction. Anger is often manifested by "acting-out" behaviors. Anxiety is usually manifested by symptoms of sympathetic nervous system arousal. Depression may be manifested by passive behaviors.

Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions should inform the client about which characteristic of this medication? a. There is risk of addiction. b. Dizziness and nausea may occur. c. Tolerance can occur with the medication. d. The medication can produce a sedating effect.

b. Dizziness and nausea may occur. Buspirone hydrochloride is used in the management of anxiety disorders. The medication has a more favorable side effect profile than do the benzodiazepines. Dizziness, nausea, headaches, lightheadedness, and paradoxical central nervous system excitement, which generally are not major problems, are side effects of the medication. The advantages of this medication are that it is not addicting, tolerance does not develop, and it is not sedating.

The nurse develops a plan of care for a 1-month-old infant diagnosed with intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent-child relationship? a. Provide educational materials. b. Encourage the parents to room-in with their infant. c. Initiate home nutritional support as early as possible. d. Encourage the parents to go home and get some sleep.

b. Encourage the parents to room-in with their infant. Rooming-in is effective for reducing separation anxiety and preserving the parent-child relationship. Educational materials may be beneficial, but they will not provide psychosocial support for the parent-child relationship. Home nutritional support is not usually necessary in the situation described. Parents are under stress when a child is ill and hospitalized, and telling a parent to go home and sleep will not relieve this stress.

The nurse is planning care for a client diagnosed with an obsessive-compulsive disorder. The nurse should assign priority to which nursing intervention? a. Monitor the client for abnormal behavior. b. Establish a trusting nurse-client relationship. c. Educate the client about self-control techniques. d. Encourage participation in daily self-care and unit activities.

b. Establish a trusting nurse-client relationship. Varcarolis (2017), p. 142. A trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. The nursing interventions identified in each of the other options may be appropriate but are not of the highest priority.

A client who has just experienced a pulmonary embolism is restless and appears very anxious. Which approach should the nurse use when communicating with this client? a. Explaining each treatment in great detail b. Giving simple, clear directions and explanations c. Having the family reinforce the nurse's directions d. Speaking very little to the client until the anxiety is decreased

b. Giving simple, clear directions and explanations The client who has suffered pulmonary embolism is fearful and apprehensive. The nurse effectively communicates with this client by staying with the client; providing simple, clear, and accurate information; and displaying a calm, efficient manner. The remaining options are likely to produce more anxiety for the client and the family.

A mother of a toddler who is hospitalized with mild dehydration must leave her child to go to work. Which behavior should the nurse expect to observe in the toddler immediately after the mother's departure? a. Playing quietly with a favorite toy b. Loudly crying and kicking both legs c. Silently curled in bed with a blanket d. Sucking his thumb and rocking back and forth

b. Loudly crying and kicking both legs The 3 stages of separation anxiety are protest, despair, and detachment. Loudly crying and kicking both legs is a protest behavior that is seen in the first stage of separation. Playing quietly reflects detachment, the third stage and final stage of separation. Options 3 and 4 are incorrect. In the stage of despair, the child is withdrawn and uses self-comfort measures.

A client wanders in and out of other clients' rooms, taking their possessions while singing to himself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action? a. Putting arms around the client, saying, "You're okay. You just need a hug." b. Saying, "I can see you are very anxious today. Let's go and play the piano." c. Taking the client to the seclusion room until he cooperates with unit rules. d. Taking the client to the lounge and saying, "Sit here and try to behave yourself."

b. Saying, "I can see you are very anxious today. Let's go and play the piano." The use of a defense mechanism allows a person to avoid the painful experience of anxiety or transform it into a more tolerable symptom, such as regression. Regression allows the threatened client to move backward developmentally to a stage in which more security is felt. The recognition of regression is a signal that the client feels anxious. The correct option will help the client feel less anxious. A hug does not address the client's anxiety. The remaining options are restrictive and degrading.

When a client diagnosed with obsessive-compulsive disorder becomes upset and agitated, he begins walking repeatedly around the nursing unit, following the same route each time late into the night. The client asks the nurse working the evening shift to walk with him. Which therapeutic response would be most appropriate when the client asks the nurse walk with him? a. "No, it is bedtime. Let me walk you back to your room." b. "Go to sleep now, but we can talk tomorrow afternoon." c. "I can see that you're upset. I will walk with you and talk for awhile." d. "I'm sorry that I'm busy right now but I'll find someone else to walk with you."

c. "I can see that you're upset. I will walk with you and talk for awhile." Varcarolis (2017), pp. 97-98, 141. The response in option 3 acknowledges the client's feelings and provides an avenue for release of the client's anxieties. Each of the incorrect options identifies a block to communication. The wording of these options does not acknowledge the client's feelings.

Immediately after taking a routine evening dose of alprazolam, a client says, "I'm not sure I should have taken that stuff." Which most appropriate statement should the nurse make to the client? a. "Anxiety is expected with any new experience." b. "You are afraid of the media claims about this medication." c. "Your depression will fade once the medication begins to work." d. "Let's talk about how you feel about taking alprazolam for a while."

d. "Let's talk about how you feel about taking alprazolam for a while." The nurse should focus on determining the reason for the client's concern. Cliché responses (option 1) do not express concern. The nurse would add anxiety to the client by mentioning media concerns. Alprazolam is used to treat anxiety, not depression.

A client diagnosed with hepatitis C is informed that the possibility of developing a chronic carrier state or liver cancer is very high. When the client asks, "Am I going to die from this?" which response should the nurse make to address the client's concern? a. "Here is a pamphlet on hepatitis C that explains the complications and prognosis." b. "Would you like to speak to a chaplain about your concerns, to get your affairs in order?" c. "You seem very upset. What did your primary health care provider tell you about these possibilities?" d. "If you take good care of yourself and follow your primary health care provider's prescriptions, everything will be okay."

c. "You seem very upset. What did your primary health care provider tell you about these possibilities?" The response, "You seem very upset. What did your primary health care provider tell you about these possibilities?" appropriately addresses the client's concern. The psychosocial needs of the client are best met when the nurse focuses the conversation on how the client is feeling and attempts to encourage self-exploration and continued conversation. Giving the client a pamphlet on hepatitis C places the client's concern on hold. Asking the client about speaking to a chaplain directs the client's concern to another health care team member when it primarily should be addressed by the nurse. Telling the client to take good care of self and follow primary health care provider's prescriptions and so everything will be okay is providing false reassurance.

A client states to the nurse, "I'm so scared to have this liver biopsy. I have been told that bleeding is a major complication, and I don't want to bleed to death." Which therapeutic response should the nurse to make to the client? a. "Bleeding is a rare complication, so try not to be concerned." b. "You have the best doctor in the world! Don't worry about anything." c. "You're feeling anxious about the procedure? Tell me more about what is worrying you." d. "You will receive medication that will make you sleep, so you won't be aware of what's happening."

c. "You're feeling anxious about the procedure? Tell me more about what is worrying you." Reflection is the therapeutic communication technique that redirects the client's feelings back to him or her to validate what the client is saying. Option 3 uses the therapeutic technique of reflection. This option also encourages the client to communicate feelings. The remaining options ignore the client's concern and feelings and block the communication process.

A client arrives in the emergency department after being in an automobile accident. The client was physically unharmed yet was hyperventilating and complaining of dizziness and nausea. In addition, the client appeared confused and had difficulty focusing on what was going on. The nurse assesses the client's level of anxiety as which level? a. Mild b. Panic c. Severe d. Moderate

c. Severe Varcarolis (2017), pp. 131-132. The person whose anxiety is assessed as severe is unable to solve problems and has difficulty focusing on what is happening in the environment. Somatic symptoms are usually present. The individual with mild anxiety is only slightly uncomfortable and may even find performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem-solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

The nurse is assessing a client with a diagnosis of acute pulmonary edema who is mechanically ventilated. The nurse determines that the client is experiencing anxiety if the client exhibits which signs? a. Hypotension, confusion, and combative behaviors b. Bradycardia, hand clenching, and startling behaviors c. Tachycardia, clinging to family members, and pupil dilation d. Tachypnea, decreased level of consciousness, and palpitations

c. Tachycardia, clinging to family members, and pupil dilation Signs of anxiety include behaviors, such as clenched hands, clinging to the family or staff, heightened awareness, wide eyes, pupil dilation, startle response, furrowed brow, or physical lashing out. Because anxiety stimulates the sympathetic nervous system, the client may also exhibit palpitations and chest pain, tachycardia, increased respiratory rate, elevated blood glucose, and hand tremors. The signs noted in option 1 would be seen with hypoxia, not anxiety. In anxious states, tachycardia is present, not bradycardia (option 2). Anxiety produces a heightened awareness, not a decreased level of consciousness (option 4).

The nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by taking which action? a. Getting angry at the supervisor b. Slamming cupboards in the office c. Telling a friend that this employee hates her d. Apologizing and offering to go out to lunch together

c. Telling a friend that this employee hates her Varcarolis (2017), pp. 136, 252. The defense mechanism of projection is an unconscious process that rejects emotionally unacceptable feelings to other people, objects, or situations and casts the blame onto another. Options 1 and 2 describe displacement, in which the feeling is transferred to another person or object. Option 4 describes reaction formation in which a behavior is used that is directly opposite to a person's unacceptable trait.

The nurse is performing a mental health assessment on a client who is suspected of having obsessive-compulsive disorder (OCD). Which client statement would affirm the presence of this disorder? a. "Sometimes I can't get the tune of a song out of my head." b. "On occasion I knock on wood in an effort to prevent something bad from happening." c. "There are times when I can't remember that I shut off my curling iron, so I have to go back and check." d. "Any time I am leaving the house, I have to unlock and relock the door approximately 30 times to make sure that it is working."

d. "Any time I am leaving the house, I have to unlock and relock the door approximately 30 times to make sure that it is working." Normal OCD behaviors do not interfere with the daily life routine on a regular basis. A tune running persistently through the mind; touching a lucky charm, knocking on wood, or making the sign of a cross upon hearing bad news; and intermittent nagging doubts as to whether appliances are shut off (options 1, 2, and 3) are examples of minor, normal obsessions and compulsions. However, these behaviors can be considered pathological if they become extreme. Pathological symptoms commonly interrupt the daily routine and interfere with relationships. The behavior described in option 4 is pathological, interrupts the daily routine, and has the potential to interfere with relationships; therefore, this is the correct option.

A client comes into the clinic stating, "I spend 2 to 3 hours every evening going over things to make sure everything I did was right. I tell myself to snap out of it, but I continue to do it even after it takes me hours each morning to get dressed because I want my clothes to be 'just right.'" The nurse analyzes the client's statements and determines that the client's behavior supports which condition? a. Agoraphobia b. A personality disorder c. Attention-deficit disorder d. An obsessive-compulsive disorder

d. An obsessive-compulsive disorder Varcarolis (2017), p. 141. Obsessions are defined as persistent thoughts that are intrusive and that the person tries to ignore or suppress. This client wants to "snap out of" this daily review, but the thoughts continue for hours. Compulsions are defined as repetitive behaviors that the client feels driven to perform, such as changing clothes frequently until she or he gets it "just right."

A preoperative client complains of anxiety accompanied by tingling in the fingers and toes. The client has a pulse rate of 100 beats per minute, a respiratory rate of 30 breaths per minute, and a blood pressure of 138/86 mm Hg. Which initial action should the nurse implement? a. Institute seizure precautions. b. Obtain an electrocardiogram. c. Obtain a prescription for midazolam. d. Encourage the client to breath slowly.

d. Encourage the client to breath slowly. The tingling in the fingers and toes is a symptom of alkalosis. Clients who are anxious and have a high respiratory rate are likely to have respiratory, not metabolic, alkalosis. The indicated initial treatment is to have the client breathe more slowly. Breathing into a paper bag also may be useful. If the condition continues, the client may benefit from a preoperative sedative medication, such as midazolam, but this would require a primary health care provider's prescription. No reason exists to obtain an electrocardiogram or initiate seizure precautions.

A client has a compulsive bed-making ritual in which the client makes and remakes the bed numerous times. The client often misses breakfast and some of the morning activities because of the ritual. Which intervention would be most helpful to the client? a. Discuss the ridiculousness of the behavior. b. Verbalize tactful, mild disapproval of the behavior. c. Help the client to make the bed so that the task can be finished quicker. d. Offer reflective feedback, such as "I see you have made your bed several times. You must be tired."

d. Offer reflective feedback, such as "I see you have made your bed several times. You must be tired." Varcarolis (2017), pp. 132-133. Reflective feedback lets the client know that the nurse acknowledges the behavior and understands that it can be very tiring. The client is usually aware of the irrationality (or ridiculousness) of the behavior. Verbalizing minimal disapproval would increase the client's anxiety and reinforce the need to perform the ritual. Helping with the ritual is nontherapeutic and reinforces the behavior.

A client has a diagnosis of dependent personality disorder. Which is the best goal the nurse should plan for this client? a. Adheres to a no-self-harm contract b. Refrains from compulsive behaviors c. Avoids situations that increase anxiety d. Uses the problem-solving process effectively

d. Uses the problem-solving process effectively Varcarolis (2017), pp. 171-172. The client with a dependent personality disorder exhibits an unusually strong need to be cared for and has difficulty making personal choices and making everyday decisions. An appropriate goal would be for the client to use the problem-solving process effectively in everyday situations. The client does not exhibit any suicidal traits. The client does not suffer from an obsessive-compulsive personality disorder or an anxiety disorder.