Anxiety Disorders

A nurse is assessing a client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is: urticaria. vertigo. diarrhea. sedation.

diarrhea. Diarrhea is the most common physiologic response to stress and anxiety. Sedation, vertigo, and urticaria could also be related to stress and anxiety but they don't occur as commonly as diarrhea.

A 54-year-old client with generalized anxiety disorder is admitted to the facility. Which therapeutic modalities are typically used to treat this disorder? Select all that apply. Fluphenazine therapy Relaxation techniques Biofeedback Buspirone therapy Electroconvulsive therapy

Biofeedback Buspirone therapy Relaxation techniques Therapy for generalized anxiety disorder includes biofeedback, buspirone therapy, and relaxation techniques. Fluphenazine is prescribed to treat schizophrenia. Electroconvulsive therapy is indicated in severe depression and some cases of schizophrenia.

As a client's level of anxiety increases to a debilitating degree, the nurse should expect which psychomotor behavior as indicating a panic level of anxiety? loss of contact with reality suicide attempts or violence desperation and rage disorganized reasoning

suicide attempts or violence Suicide attempts and violence are psychomotor responses to a panic level of anxiety. Desperation and rage are emotional responses. Disorganized reasoning and loss of contact with reality are cognitive responses.

A nurse is admitting a client diagnosed with psychogenic amnesia. The client is in apparent good health. The nurse would expect the client to exhibit which of the following behaviors? exhibiting fluctuating levels of speech functioning exhibiting a preoccupation with discovering a true identity demonstrating disinterest toward the impact of the memory loss switching from one distinct personality to another

demonstrating disinterest toward the impact of the memory loss A client with psychogenic amnesia blocks a severe or traumatic anxiety-producing event and is likely to react with disinterest to the loss of memory and identity. The client will not have a desire to discover one true identity, because this forces the client to remember the event and confront the anxiety. The client will also not experience personality switches; this is associated with dissociative identity disorder. Fluctuating level of speech is more common with dementia.

A client has just been diagnosed with panic disorder. Which medication does the nurse anticipate administering for this diagnosis? propranolol clozapine fluoxetine diazepam

fluoxetine Selective serotonin reuptake inhibitors such as fluoxetine are the medications of choice for panic disorder. Propranolol and diazepam are occasionally used for the short-term management of this disorder; however, these are not the preferred medications. Clozapine may trigger the development of an anxiety disorder.

The client with a diagnosis of posttraumatic stress disorder tells the nurse he wishes that he had been on the airplane that crashed and killed his wife and children a month ago. The nurse assesses the client's statement to be an example of which symptom? survivor guilt dysfunctional grieving numbing of responsiveness suicidal ideation

survivor guilt With posttraumatic stress disorder, the client experiences survivor guilt or feelings of guilt related to being alive.The client's statement does not indicate suicidal ideation.Dysfunctional grieving is inaccurate because the accident occurred only a month ago.Numbing of responsiveness pertains to having a restricted affect, a limitation in the range of feelings, a feeling of detachment from others and the external world, and hopelessness or lack of expectations about the future.

A client diagnosed with agoraphobia who experiences panic attacks is talking with a nurse about the progress made in treatment. Which client statement indicates a positive response to treatment? "I'm taking my medication to prevent the panic attacks." "I went to the mall with my friend last Saturday." "I find that it is difficult for me to do my everyday tasks." "I'm doing crafts and cooking while at home."

"I went to the mall with my friend last Saturday." Clients with agoraphobia tend to be socially withdrawn. Going to the mall is a sign of working on avoidance behaviors and is a positive response to treatment. Doing activities at home is not a positive change from the avoidance behavior. Inability to do everyday tasks is not showing improvement of the withdrawn behavior. It is good that the client is taking medications, but this is not a positive behavioral change to the avoidance behavior.

The client, who is a veteran and 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 response by the nurse is appropriate? "You did what you had to do at that time." "Maybe you didn't kill as many people as you think." "War is a terrible thing." "How many people did you kill?"

"You did what you had to do at that time." 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.

A nurse in a psychiatric inpatient unit is caring for a client with generalized anxiety disorder. As part of the client's treatment, the psychiatrist orders lorazepam, 1 mg by mouth three times per day. During lorazepam therapy, the nurse should remind the client to: avoid aged cheeses. stay out of the sun. avoid caffeine. maintain an adequate salt intake.

avoid caffeine. Ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for clients receiving lithium.

The nurse has completed teaching a client about alprazolam. Which statement by the client will the nurse document as evidence of successful teaching? "I should drive carefully until I know whether this causes dizziness." "This medication carries a risk of dependence." "I won't become addicted if I take it as prescribed." "I should take it at bedtime to feel calm in the morning."

"This medication carries a risk of dependence." Alprazolam can be addictive even when taken as prescribed. Alprazolam can cause drowsiness and dizziness, so the client should be told to avoid driving or operating machinery until the effects are known; merely exercising care during this time is insufficient. Alprazolam is short-acting, so it will not help morning anxiety if taken at bedtime.

A nurse is interviewing a client with posttraumatic stress disorder (PTSD) when a loud, booming noise from a passing car's radio rattles the windows. The client jumps onto a chair, wide-eyed and frantic. Which statement by the nurse is the most therapeutic response? "Take my hand and I'll help you down." "Loud noises cause you to become very upset." "What kinds of feelings are you experiencing?" "Have you experienced this kind of thing before?"

"What kinds of feelings are you experiencing?" The client's response is out of proportion to the situation. This behavior is characteristic of clients with PTSD, who are reliving a traumatic event and can't process the situation logically. Asking what feelings the client is experiencing provides an opportunity for therapeutic ventilation of emotions by allowing the client to express feelings the external stimulus has triggered. This approach may relieve the stress enough so the nurse can help the client safely off the chair. Offering to help the client down from the chair doesn't address the client's current personal reality. Using paraphrasing technique that the client is experiencing anxiety from loud noises is helpful but not as good as asking for more specific feelings from the client.

A client reports experiencing symptoms of stress including nausea, sweating, irritability, and some difficulty sleeping since getting married and becoming a step-parent. The client has always believed symptoms will go away on their own. The nurse is educating the client about stress management. Which statement by the nurse is most appropriate? "Using stress management techniques will help you focus on what is causing your anxiety." "Using stress management techniques will help you calm down and relax." "Using stress management techniques will help you challenge the validity of your physical symptoms." "Using stress management techniques will reduce your anxiety until you feel your legs go numb."

"Using stress management techniques will help you calm down and relax." Stress management techniques are meant to reduce anxiety and promote calmness. The goal of using stress management techniques is not to challenge the validity of physical symptoms; this would promote more rumination on the source of the anxiety. Using stress management techniques should not help the client focus on what is causing the anxiety, but rather to distract the client. The client should not strain muscles to the point of numbness.

A client is brought to the emergency department experiencing a spontaneous episode of extreme terror, palpitations, tachycardia, tremor, and shortness of breath. The client describes a fear of dying or going crazy. The healthcare provider rules out physiologic causes. The nurse advocates for the client to receive which medication? diazepam buspirone lorazepam clonazepam

lorazepam Of all the antianxiety agents listed, lorazepam can provide symptomatic relief for panic attacks due to its being available as a sublingual route and its short onset time. Diazepam and clonazepam are long-acting with a longer onset of action, making them inappropriate for an acute panic attack. Buspirone takes 14-30 days for therapeutic effect.

The nurse is teaching a client prescribed the antianxiety agent chlordiazepoxide. The nurse should incorporate which instruction into the teaching plan? Take antianxiety drugs in the morning with breakfast or a snack. Take the medication at the same time each day, avoiding taking at bedtime. Avoid taking antianxiety drugs with alcohol. Avoid consuming items with tyramine when taking antianxiety agents.

Avoid taking antianxiety drugs with alcohol. The client should be instructed to avoid alcohol while taking chlordiazepoxide because alcohol potentiates the drug's CNS depressant effect. Taken at bedtime, this drug will induce sleep and can potentiate the effects of other drugs. Chlordiazepoxide comes in capsule form and can usually be taken with water any time of day. Tyramine is restricted with monoamine oxidase inhibitors, not antianxiety agents.

A client who had been sexually assaulted as a young girl saw her assailant after 5 years. She cut her wrists and was brought into the emergency department by a family member who discovered her hiding on a closet floor. Which questions should the nurse ask to assess the client's perception of this event? Select all that apply. "Describe how you are feeling now." "What helped you through difficult times in the past?" "Who can you talk to when you feel overwhelmed?" "Who is available to help you?" "What was happening in your life before you started to feel like hurting yourself?" "Has anything upsetting happened to you within the past few days or weeks?"

"Has anything upsetting happened to you within the past few days or weeks?" "What was happening in your life before you started to feel like hurting yourself?" "Describe how you are feeling now." In order to clearly define the problem, the nurse needs to assess the client's perception of the precipitating events. The question of whether anything upsetting happened to her within the past few days or weeks, what was happening in her life before she started to feel like hurting herself, and requesting the client to describe how she is feeling all reflect how the client is perceiving the problem now. The questions about who can the client talk to when feeling overwhelmed, who is available to help her, and what has helped her during difficult times in the past are situational support assessment questions.

A client with an anxiety disorder is admitted to the psychiatric unit because of panic attacks. What statement by the nurse is the most appropriate? "I am going to ask you some questions to help me understand the anxiety you are experiencing." "When you start feeling anxious, I will ask you some simple questions to better understand what you are going through." "I want to help you feel better, please come and talk with me when you are ready." "I will wait to ask you any questions until you feel a little more comfortable on the unit."

"I am going to ask you some questions to help me understand the anxiety you are experiencing." Nursing assessment questions for clients with anxiety disorders and panic attacks need to be direct and straightforward. Clients with anxiety disorders with panic attacks are fearful about the future and may be reluctant to initiate talking about their anxiety. Knowing the questioning will be coming in an uncertain amount of time will trigger more anxiety. In high anxiety, the brain is not functioning properly and the person is not able to think or process information clearly.

During the interview, the client with schizophrenia is experiencing an anxiety attack. Which of these responses by the nurse would be most appropriate? "If you don't watch out, you will lose control again." "What is making you so anxious?" "I will stay with you." "Calm down, there is nothing to be upset about."

"I will stay with you." Reassuring the client helps the client gain a sense that the nurse can be trusted and is there to offer support. The other responses are authoritarian or judgmental and are likely to increase anxiety.

The nurse is caring for a client with social anxiety disorder. Which statement by the client is of concern for the nurse? "I'll remember that my feelings are irrational." "I'll practice asking a person out on a date before I actually do it." "I'll have a drink before having lunch with a friend." "I'll try to eat lunch with my coworker."

"I'll have a drink before having lunch with a friend." Clients with phobic disorders are prone to engaging in episodic alcohol or drug abuse in an attempt to overcome phobia-related anxiety. This is an ineffective way to deal with anxiety. Therefore, a statement signaling that using alcohol as a coping mechanism should concern the nurse. Attempting to eat lunch with a coworker and expressing a desire to ask someone for a date reveals that the client is taking small steps toward overcoming their fears. In remembering that their feelings are irrational, the individual can overcome the power that anxiety can have over them, and they can be in control.

The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take? Instruct the client to put the head between the knees. Tell the client to take several deep, slow breaths and exhale normally. Give the client a low concentration of oxygen by nasal cannula. Have the client breathe into a paper bag.

Have the client breathe into a paper bag. The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise carbon dioxide level, which encourages deeper, slower breathing. The symptoms of hyperventilation will not be alleviated by having the client put the head between the knees, giving the client low concentrations of oxygen, or having the client take deep, slow breaths and exhaling normally.

A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience: heightened concentration. a decreased heart rate. a decreased respiratory rate. a decreased perceptual field.

a decreased perceptual field. Panic is the most severe level of anxiety. During a panic attack, a client's perceptual field, narrows. The client becomes more self-focused, less aware of surroundings, and unable to process information from the environment. The client's decreased perceptual field impairs attention and ability to concentrate. During an acute panic attack, the client may experience an increase, not a decrease, in heart and respiratory rates, resulting from stimulation of the sympathetic nervous system.

While a client is taking alprazolam, which food should the nurse instruct the client to avoid? shellfish cheese alcohol Chocolate

alcohol 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.

After learning that a roommate is HIV-positive, a client asks a nurse about moving to another room on the psychiatric unit because the client no longer feels "safe." What should the nurse do first? Ask the client to describe the fears. Explain that such a move wouldn't be therapeutic for the client or the roommate. Move the client's roommate to a private room. Move the client to another room.

Ask the client to describe the fears. To intervene effectively, the nurse must first understand the client's fears. After exploring the fears, the nurse may move the client or roommate or explain why such a move wouldn't be therapeutic, as needed.

During alprazolam therapy, the nurse should be alert for which dose-related adverse reaction? urticaria ataxia hepatomegaly rash

ataxia Dose-related adverse reactions to alprazolam include drowsiness, confusion, ataxia, weakness, dizziness, nystagmus, vertigo, syncope, dysarthria, headache, tremor, and a glassy-eyed appearance. These dose-related reactions diminish as therapy continues. Although hepatomegaly may occur with benzodiazepine use, this adverse reaction is rare and isn't dose-related. Idiosyncratic reactions to benzodiazepines may include a rash and acute hypersensitivity reactions; however, these reactions aren't dose-related.

A client with acute stress disorder states to the nurse, "I keep having horrible nightmares about the car accident that killed my daughter. I should not have taken her with me to the store." Which response by the nurse is most therapeutic? "Let's talk about something that's a bit more pleasant." "Don't keep torturing yourself with such horrible thoughts." "The accident just happened and couldn't have been predicted." "Stop blaming yourself. It's only hurting you."

"The accident just happened and couldn't have been predicted." Saying "The accident just happened and couldn't 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's a bit more pleasant" ignores the client's feelings and changes the subject. The client needs to verbalize feelings and decrease feelings of isolation.

What should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety? cognitive and behavioral strategies appropriate rest and sleep habits issue avoidance and denial of problems withdrawal from role expectations and role relationships

cognitive and behavioral strategies A client with generalized anxiety disorder needs to learn cognitive and behavioral strategies to cope with anxiety appropriately. In doing so, the client's anxiety decreases and becomes more manageable. The client may need assertiveness training, reframing, and relaxation exercises to adaptively deal with anxiety. The nurse would not teach how to avoid or deny problems or become withdrawn as these would increase anxiety and potentially promote depression. Appropriate rest and sleep are necessary for all clients, but do not directly assist the client in dealing with anxiety.

A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet. The client repeatedly checks to see if the clothing is arranged in the proper order. What term is commonly used to describe this behavior? transference compulsion exhibitionism obsession

compulsion Compulsion is present when a client performs recurrent, persistent, repetitive actions and behaviors that the client feels driven to perform. This behavior interferes with the client's activities of daily living and disrupts the lifestyle. These compulsions relieve the intense anxiety experienced when the client doesn't act on them. Obsession is a recurrent, persistent, and intrusive thought. Exhibitionism is the compulsive need to expose a part of one's body, especially the genitals, to an unsuspecting stranger. Transference is the process of projecting one's feelings and thoughts onto the therapist, who symbolically represents a significant person in the client's past.

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy would most the nurse expect to see included in the plan of care? behavior therapy psychoanalysis insight therapy group therapy

behavior therapy 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.

A nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist the compulsion. Based on this finding, the nurse should assess the client for: feelings of failure. depression. increased anxiety. excessive fear.

increased anxiety. An obsessive-compulsive client who attempts to resist the compulsion must be evaluated for increased anxiety. A compulsion is a repetitive, intentional behavior that the client performs in response to a certain obsession; it's aimed at neutralizing or decreasing anxiety. Resisting the compulsion may increase the client's anxiety. Although a client with OCD may experience a sense of failure, depression, and excessive fear, these feelings aren't responses to resisting the compulsion.

A client with posttraumatic stress disorder states, "You don't know what I've been through. What can you do?" The nurse should respond: "I'd like to help you if you'll let me." "Perhaps you'll feel better if you can become interested in a hobby once again." "I need to refer you to a survivors' group where you'll feel more comfortable." "I haven't been through what you have, but I'll be better able to understand if you tell me more about it."

"I haven't been through what you have, but I'll be better able to understand if you tell me more about it." Saying that the nurse has not been through what the client has is nonjudgmental, supportive, and conveys honesty and empathy to the client. Telling the client he will feel more comfortable in a survivors' group dismisses the client. However, a survivors' group may be needed later. Stating that the client should become interested in a hobby dismisses his feelings and is not helpful. Saying that the nurse would like to help if the client would allow it implies that the client is not being cooperative; it may alienate him.

The client rushes out of the day room where he has been watching television with other clients. He is hyperventilating and flushed and his fists are clenched. He states to the nurse, "That bastard! I almost hit him." What would be the nurse's best response? "You're angry, and you did well to leave the situation. Let's walk up and down the hall while you tell me about it." "I'm glad you left the situation. Go to your room and calm down. I'll come in soon to talk." "I can see you're angry. Let me get you some lorazepam to help you calm down. Then we'll talk about what happened." "Even if you're angry, you can't use that language here."

"You're angry, and you did well to leave the situation. Let's walk up and down the hall while you tell me about it." The nurse acknowledges and labels the client's emotion and acknowledges his appropriate behavior. Recognizing the client's physiologic arousal, the nurse suggests an activity to decrease anxiety and stays with him. Setting limits on the client's language does not acknowledge his control and does not help the client manage his anxiety. The client needs to engage in physical activity to decrease muscle tension and anxiety. Offering the client medication suggests that he cannot control his behavior. Medication would be used only if other interventions failed to reduce the anxiety level.

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care? helping the client identify any stressors or psychological conflicts exploring personal relationships that may be related to the paralysis teaching the client to deal with any limitations of the paralysis helping the client identify and verbalize their feelings about the incident

helping the client identify and verbalize their feelings about the incident In functional neurologic symptom disorder, the client represses and converts emotional conflicts into motor, sensory, or visceral symptoms that have no physiologic cause. All of these interventions are appropriate for this client. However, the client needs first to express feelings that can help to reduce anxiety and anger, and lead to understanding and insight into the situation. The other actions are necessary, but not immediately.

After being discharged from the hospital with acute stress disorder, a client is referred to the outpatient clinic for follow-up. What is most important for the client to use for continued alleviation of anxiety? understanding reasons for her anxiety describing the situations preceding her feelings of anxiety using adaptive and palliative methods to reduce anxiety recognizing when she is feeling anxious

using adaptive and palliative methods to reduce anxiety 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.

A client with borderline personality disorder tells a nurse, "You're the only nurse who really understands me. The others are mean. They always ignore me when I ask for my extra antianxiety medication." How should the nurse respond? "I'll inform the team of your concerns. Let's talk about how you're feeling." "You know you can't have extra antianxiety medication according to your plan of care." "I know the other nurses follow the rules for giving medications." "You will have to talk with your healthcare provider about how the medication order is written."

"I'll inform the team of your concerns. Let's talk about how you're feeling." Telling the client that it is important for them to talk about how they are feeling is an appropriate response, as it focuses on the emotional content of the client's message and helps the client identify their feelings. Focusing on the request for extra medication would allow the client to ignore the underlying emotional issues. Clients with borderline personality disorder commonly split the staff into "good guys" and "bad guys" to meet their needs; staff members must maintain consistency and a united front at all times. The nurse should not take the client's statements personally, as doing so would interfere with the nurse's ability to maintain a therapeutic relationship.

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 which factor? safe expression of hostility. attention from others. control of his thoughts. relief from anxiety.

relief from anxiety. 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.

A nurse is caring for a client with obsessive-compulsive disorder (OCD) with rituals of washing hands, folding and unfolding towels, and switching the bathroom light on and off multiple times prior to meals. What action should the nurse take? Interrupt the client's ability to complete the rituals. Gradually limit the time allowed for the client to complete the rituals. Allow ample time for the client to complete the rituals. Assist the client in completing the rituals.

Gradually limit the time allowed for the client to complete the rituals. When caring for a client with OCD, the long-term goal is to systematically decrease the undesirable behavior. This is done by helping the client gradually decrease the anxiety that drives the behaviors and, in concert, gradually limiting the time available to perform the rituals. Interrupting the client's rituals will create more anxiety. Getting involved in the client's rituals will make it worse because it reinforces the importance of the ritual. Allowing unlimited time for the client to perform the rituals is appropriate in the early stages of treatment while medications are first begun, but it will not help extinguish the behavior.

An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. During the admission assessment, which behaviors would be characterized as compulsions? Select all that apply. repeatedly washing the hands checking and rechecking that the television is turned off before going to school wanting to play the same video game each night routinely climbing up and down a flight of stairs three times before leaving the house spending the night at only one friend's house brushing teeth three times per day

checking and rechecking that the television is turned off before going to school repeatedly washing the hands routinely climbing up and down a flight of stairs three times before leaving the house Compulsions involve symbolic rituals that relieve anxiety when they are performed. The disorder is caused by anxiety from obsessive thoughts, and acts are seen as irrational. Examples include repeatedly checking the television set, washing hands, or climbing stairs. An activity such as playing the same video game each night or spending the night at a friend's friend, maybe a best friend's house, may be indicative of normal development for a school-age child. Frequent brushing of the teeth is not abnormal.

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for this client at this time? risk for injury ineffective coping hopelessness disturbed personal identity

risk for injury This client is at increased risk for injury because of severe hyperactivity, disorientation, and agitation. Although ineffective coping, hopelessness, and disturbed personal identity also are appropriate diagnoses, the client's safety takes highest priority. The nurse should take immediate action to protect the client from injury.

A nurse is caring for a veteran with a history of explosive anger, unemployment, and depression since being discharged from the service. The client reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response? "It isn't too late for you to make changes in your life." "You can change your behavior if you're motivated to do so." "Many people who've been in your situation experience similar emotions and behaviors." "Weak people don't want to make changes in their lives."

"Many people who've been in your situation experience similar emotions and behaviors." By providing reassurance that extreme anger and other reactions are normal responses to trauma, the nurse assists the client to deal with shame over a perceived lack of control over feelings and to gain confidence in the ability to alter behaviors. Assuring that the client can change behavior and saying that weak people don't want to make changes are cliché statements and don't address the client's feelings.

A newly admitted young adult client, diagnosed with posttraumatic stress disorder (PTSD), reluctantly reveals that she was the victim of human trafficking 2 years ago. The client says, "Nobody will ever believe the horrible things the men did to me, and no one never stopped them." Which response is appropriate for the nurse to make? "I'll believe anything you tell me. You can trust me." "It must be difficult to talk about what happened. I'm willing to listen." "Tell me what the men did to you. It's important that I understand the details." "I can't understand why society did not do more to protect you. It's not right."

"It must be difficult to talk about what happened. I'm willing to listen." 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. Knowing the details is not necessary to provide care and puts pressure on the client to relive painful memories. Believing everything may or may not be possible and does not convey the empathy. Saying that it was not right that society did not help diverts attention from the client.

The client is shaking and is reporting a high degree of stress about hospitalization. Which nursing intervention is most appropriate? Offer the client a prescribed sedative. Encourage the client to listen to music. Have the client use meditation by repeating a word out loud. Instruct the client to inhale and exhale slowly.

Instruct the client to inhale and exhale slowly. The least restrictive action to help reduce anxiety would be focused breathing. Offering a sedative should be used after other interventions have failed. Having the client repeat a word may be stimulating and lead to increased anxiety. Listening to music might also be stimulating and increase the symptoms of anxiety.

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 is going crazy. Which intervention should the nurse use first? Explain the effects of stress on the mind and body. Reassure the client that her feelings are typical reactions to serious trauma. Reassure the client that her symptoms are temporary. Acknowledge the unfairness of the client's situation.

Reassure the client that her feelings are typical reactions to serious trauma. 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.

The nurse is assessing a client who has just experienced a crisis. The nurse should first assess this client for which behavior? capability of effective problem solving increased level of anxiety shortened attention span seeks help from others

increased level of anxiety During the first phase of crisis, the client exhibits elevated anxiety. A client who can use problem-solving capabilities is not in crisis. A shortened attention span is characteristic of the fourth phase of crisis. Reaching out to others for help is indicative of the third phase of crisis.

A client who is a painter recently fractured a tibia and can't work. The client worries about finances. To treat the client's anxiety, the physician orders buspirone, 5 mg by mouth three times per day. Which drugs interact with buspirone? monoamine oxidase (MAO) inhibitors beta-adrenergic blockers antineoplastic drugs antiparkinsonian drugs

monoamine oxidase (MAO) inhibitors Buspirone interacts only with MAO inhibitors, producing a hypertensive reaction. Administration of beta-adrenergic blockers, antineoplastic drugs, or antiparkinsonian drugs wouldn't cause an interaction, so they can be administered simultaneously with buspirone.

An 18-year-old pregnant college student presented at the prenatal clinic for an initial visit at 14 weeks' gestation. The client's history revealed that she has taken fluoxetine 20 mg orally daily for posttraumatic stress disorder (PTSD) and depression. Her medication was recently increased to 40 mg daily because of reports of increased stress and suicide ideation. Which side effect of fluoxetine would the nurse judge to be the greatest risk for the client and her developing fetus at this stage in her pregnancy? headache insomnia decreased libido nausea/anorexia

nausea/anorexia Growth of the fetus is important, so nausea and anorexia that would interfere with the young woman's nutrition would cause the most harm to the developing fetus. It could also lead to electrolyte imbalance if she did not take in enough fluid. While insomnia could cause problems long-term, this side effect could be mitigated through adjustment of the dosing time (earlier in the day), by decreasing the dosage to her former 20 mg daily, or by changing to every other day dosing of 40 mg, since fluoxetine has a long half-life. Headaches are uncomfortable but can be treated with mild analgesics or other treatments, such as cold cloths, that would not harm the fetus. Decreased libido, while not enjoyable for the client or her sexual partner, does not pose any risks for the fetus.

An adolescent 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 occasionally miss a day of school. He is concerned that these attacks may hinder his ability 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? "You're putting too much pressure on yourself. You just need to relax more, and things will be alright." "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." "It's natural to be worried about going into a new environment. I'm sure with your abilities you'll do well once you get settled." "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."

"It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." The client's concerns are real and serious enough to warrant assessment by a health care provider (HCP) 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.

The nurse is caring for a client who has been admitted for inpatient psychiatric treatment after being diagnosed with somatic symptom disorder. When planning the client's care, it will be important for the nurse to consider which aspect of treatment? ensuring the option for alternative medicines administering antipsychotic medications providing instruction and assessment for stress management techniques providing behavior modification for the family

providing instruction and assessment for stress management techniques Conditions of stress exacerbate somatic symptom disorder. Alternative medicines are not proven to benefit people with this disorder. Psychotic symptoms are not common or present in this case, so antipsychotic medications are not indicated. Behavior modification would be appropriate for the client and is not indicated for the family.

A client is scheduled for cardiac catheterization the next morning. The physician ordered temazepam, 30 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that: sedatives cause predictable responses; hypnotics cause unpredictable ones. sedatives don't depress respirations; hypnotics do. sedatives interact with few drugs; hypnotics interact with many. sedatives reduce excitement; hypnotics induce sleep.

sedatives reduce excitement; hypnotics induce sleep. Sedatives are drugs that act to reduce activity or excitement, calming a client. Hypnotics induce a state resembling natural sleep. Sedatives and hypnotics cause predictable responses, interact with many drugs, and can cause respiratory depression.

A client presents to the nurses' station with symptoms of a panic attack, including shortness of breath, dizziness, trembling, and nausea. Which is the nurse's first intervention? Teach the client relaxation techniques. Stay with the client, and offer support. Administer PRN antianxiety medication. Help the client identify triggers for anxiety.

Stay with the client, and offer support. Staying with the client and offering support will provide a sense of security. Never leave a client alone during a panic attack. Teaching relaxation techniques and helping the client identify triggers are not appropriate during an acute panic attack, but they are important interventions when the client is calmer and able to receive information. Administering anxiety medication isn't the best initial action, because they don't take effect immediately.

A client with posttraumatic stress disorder has been complaining of headaches. The healthcare provider orders magnetic resonance imaging (MRI) of the brain to rule out organic disorders. The client later tells a nurse, "I'm not going into that tunnel!" Which response by the nurse is most therapeutic? "I can tell you're really afraid. Can you tell me more about your fear?" "Try to take several slow, deep breaths; it will reduce your anxiety." "Being anxious is completely normal. You'll be fine." "Calm down. Are you trying to tell me something important?"

"I can tell you're really afraid. Can you tell me more about your fear?" The client is experiencing intense fear. Rather than reasoning with the client, the nurse should use the refusal as an opportunity to learn more about the client's feelings. Clients want to feel like they are understood. Acknowledging the client's expressed fears both focuses on the feelings and encourages the client to talk about those feelings. Expressing feelings may make the client more receptive to the MRI. Telling the client to calm down would likely increase the client's anxiety. Taking deep breaths might benefit the client later, but this suggestion disregards and discounts the currently expressed fear. Telling the client that they will be fine is not appropriate, because it minimizes feelings and provides false reassurance.

A 40-year-old client is admitted for a surgical biopsy of a suspicious lump in the left breast. The client is tearfully writing a letter to the client's two children and tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours." "Try to take a few deep breaths and relax. I have some medication that will help." "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it." "In case anything goes wrong? What are your thoughts and feelings right now?"

"In case anything goes wrong? What are your thoughts and feelings right now?" By acknowledging how the client feels, this response encourages discussion about what the client is thinking and feeling. Minimizing the client's feelings or offering empty reassurances isn't therapeutic or helpful. Deep breathing and preoperative medication would be appropriate only after the client has expressed the fears and dealt with them.

A client with a moderate level of anxiety is pacing quickly in the hall and tells the nurse, "Help me. I can't take it anymore." What would be the nurse's best initial response? "Try doing your relaxation exercises to calm down." "I'll get some medicine to help you relax." "Let's go to a quieter area where we can talk if you want." "It would be best if you would lie down until you are calmer."

"Let's go to a quieter area where we can talk if you want." For a client with moderate anxiety, the nurse should initially lead the client to a less stimulating environment and help him discuss his feelings. Doing so helps the client to gain control over anxiety that could be overwhelming. Telling the client that it would be best to lie down until he is calmer is not appropriate because the client is too anxious to benefit from this intervention. Suggesting that the client try relaxation exercises could be helpful after the nurse takes the client to a less stimulating environment and allows the client to vent and discuss his feelings. Getting some medication to help the client relax is an intervention that the nurse would carry out later after trying to help the client decrease anxiety through ventilation and relaxation exercises.

An abused woman tells the nurse that her 8-year-old daughter refuses to go to school because she is afraid her mother will not be home when she returns. What is the most therapeutic response for the nurse to make? "Children often feel responsible for trouble in the family. Have you talked with her about what she's afraid might happen?" "She's aware of the trouble in the family and is worried about what might happen. Would you like to have her talk to the child therapist here? I think it would be helpful." "You know she's too young to be home alone after school. If you can't be there, you should find someone else to meet her so she won't be afraid." "She must be feeling insecure right now. Let her stay home with you for a few days to reassure her."

"She's aware of the trouble in the family and is worried about what might happen. Would you like to have her talk to the child therapist here? I think it would be helpful." It is important that the nurse address the family problem and include the client in making decisions about her daughter. Allowing the child to remain at home or having someone else at home to meet her ignores the basic family problem. Asking the client to talk to her daughter is appropriate but is not a sufficient intervention in this situation.

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped? "Have you tried walking to ease your anxiety?" "What are you thinking about before you start to prepare supper?" "What do you do when you're anxious to help yourself feel better?" "Do you think taking several slow, deep breaths would help?"

"What are you thinking about before you start to prepare supper?" The nurse initially helps the client to identify a cause or event that precedes the symptoms of anxiety. Nursing care of an anxious client, however, must ultimately take into account all aspects of the client's anxiety, including what leads to attacks and what happens during an attack. Only then can the nurse help the client understand his anxiety, what personal needs may be unmet, and how to cope with his problem with more satisfactory behavior than having an anxiety attack. The nurse must first assess the possibility of a trigger for the client's anxiety before progressing to assessing the client's coping strategies or educating him regarding adaptive coping.

A young school-age girl whose mother and aunt have been diagnosed as having bipolar disorder and whose father is diagnosed with depression is brought to the clinic because of problems with behavior and attention in school and inability to sleep at night. The child says, "My brain does not turn off at night." The child is diagnosed as experiencing attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well. What should the nurse say to the father to explain what the provider said? Select all that apply. "The child's description of her inability to sleep is irrelevant to diagnosing her condition since she stays up late." "Your provider is considering a bipolar diagnosis because of your child's family history of bipolar disorder and her sleep issues." "Your child was diagnosed as having ADHD because of her attention and behavior problems at school." "Your provider does not know how to diagnose your child's illness since she has symptoms of both bipolar disorder and ADHD." "ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings."

"Your child was diagnosed as having ADHD because of her attention and behavior problems at school." "ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings." "Your provider is considering a bipolar diagnosis because of your child's family history of bipolar disorder and her sleep issues." The client's school problems, the presence of first-degree relatives diagnosed with bipolar disorder and depression, and her inability to sleep at night mirror aspects of both ADHD and bipolar disorder, which are difficult to distinguish from each other in children. Health care providers (HCPs) are reluctant to diagnose young children as bipolar at this age. She may have only one disorder or the other or both. Further monitoring and her response to medication will differentiate whether she is suffering from one of the disorders or both. Any comments indicating that the provider does not know what he or she is doing or that the child's perceptions of her illness are not valid will undermine any trust the father and child might be developing in their caregiver and so should be avoided.

The client with obsessive-compulsive disorder eats slowly and is always the last to finish lunch, which makes it difficult for the group to start at 1300. Which approach would be the best plan of action for this problem? Inform the client that he will have to eat faster so that the group can begin on time. Begin the group without the client so that he will have ample time for his lunch. Arrange for the client to start eating earlier than the others. Change the time of the group to accommodate the client.

Arrange for the client to start eating earlier than the others. Letting the client eat earlier meets his needs for more time and also the group's need to start on time. It also protects the client from being resented by others and lets him be included in the group activity.Changing the time of an activity to meet one client's needs is undesirable and may be impractical as well.Beginning the group activity without the client will result in decreasing the client's self-esteem and increasing anxiety and the need to maintain his symptoms.Telling the client he will have to eat faster blames the client and results in increased anxiety and guilt and further reinforces the need for compulsive behavior.

The nurse is assessing a client with somatic symptom disorder who reports a fall. The nurse finds the client rubbing the left knee. How should the nurse best intervene? Assess the client's injury, notify the healthcare provider, and document the incident. Assess the client's injury, offer the client a bandage wrap, and document the incident. Report the client's injury to the healthcare provider, offer to assist with ambulation, and document the incident. Assess the client's injury, offer the client an ice pack, and document the incident.

Assess the client's injury, notify the healthcare provider, and document the incident. The nurse should assess the injury, notify the healthcare provider, and thoroughly document the incident in accordance with facility protocol. Even though a patient with somatic symptom disorder is likely to have many physical complaints, the nurse should thoroughly investigate each complaint to avoid overlooking a serious problem. The nurse should always notify the healthcare provider of the findings in accordance with facility protocol.

A nurse is providing care for a client vulnerable to panic attacks who is acutely anxious. The client currently has a respiratory rate of 28 breaths/min and a heart rate of 110 beats/min. What action does the nurse perform first? Administer antianxiety medications as prescribed. Perform a focused respiratory assessment. Coach the client on performing slow, deep breaths. Request STAT cardiac monitoring.

Coach the client on performing slow, deep breaths. Although antianxiety drugs provide symptomatic relief during a panic attack, the nurse should first attempt to coach the client to reduce the feelings of anxiety and panic, if possible. The scenario does not present any complaints of chest pain, so cardiac monitoring is not indicated at this time. Although the nurse could conduct a focused respiratory assessment, slowing the respiratory rate would be attempted first. The slower respiratory rate will help reduce the risk for respiratory alkalosis developing and enable better auscultation of breath sounds.

A client witnessed a child's death from an abusive parent 8 months ago. A family member brings the client to the clinic due to behavior that makes the family suspect the client has posttraumatic stress disorder (PTSD). What question(s) should the nurse include in the assessment to support this diagnosis? Select all that apply. Have you experienced memories in which you feel you are reliving the terrifying event? Do you have outbursts of irritability or anger that seem exaggerated? Do you find yourself avoiding anything that will remind you of the terrifying event? Do you have difficulty remembering aspects of the terrifying event? Have you had nightmares about the terrifying event?

Have you experienced memories in which you feel you are reliving the terrifying event? Do you find yourself avoiding anything that will remind you of the terrifying event? Have you had nightmares about the terrifying event? Do you have outbursts of irritability or anger that seem exaggerated? Do you have difficulty remembering aspects of the terrifying event? The criteria for PTSD includes a pattern of behaviors that occur 3 months or more after a crisis. In PTSD, the person re-experiences the event through symptoms of nightmares and flashbacks. The person attempts to avoid reminders of the trauma and exhibits sleep disturbances, angry outbursts, and memory issues related to the trauma. Personal relationships are often damaged.

A client is admitted to the emergency department with diaphoresis, chest pain, vertigo, and palpitations. On initial assessment, it appears there is no physiologic basis for the client's symptoms. The client is seen by the psychiatric emergency department nurse who, on recognition that the client has had four similar episodes in the past month, suspects the client has a panic disorder. Which intervention should the nurse perform? Ask the client to detail the current symptoms. Educate the client about the support groups available. Instruct the client how to monitor respirations and pulse rate. Maintain a calm approach that is not threatening.

Maintain a calm approach that is not threatening. Clients with a panic disorder need the staff to remain calm. Anxiety, like calmness, can be transferred between the client and nurse. Asking for detail about the symptoms is likely to cause more anxiety in the client. Having the client pay more attention to vital signs is not appropriate at this time. The nurse should give only the information the client needs on an elemental level. Providing information about a support group is not appropriate in the acute situation. Once the client's anxiety level has been reduced, assessments for other underlying psychiatric issues could be explored, but the client should not be assailed with questions at this time.

Which nursing action would be therapeutic for the client being admitted to the unit with panic disorder? Select all that apply. Support the client's attempts to discuss feelings. Confront the client's dysfunctional coping behaviors. Reassure the client of safety. Touch the client to provide contact with reality. Respect the client's personal space.

Respect the client's personal space. Reassure the client of safety. Support the client's attempts to discuss feelings. Supporting the client's attempts to discuss feelings conveys empathy and is a therapeutic response.Respecting personal space demonstrates caring and helps to prevent escalation of anxiety.Reassuring the client about safety promotes a therapeutic nurse-client relationship and prevents escalation of anxiety.Touching the client or confronting dysfunctional coping behaviors or defense mechanisms will most likely be viewed as a threat and will increase anxiety.

A nurse is admitting a client who is experiencing a panic attack. Physiologic causes have been ruled out. The assessment reveals the client has difficulty breathing, chest pain, and palpitations. The client is pale, with the mouth wide open and eyebrows raised. What should the nurse do first? Place the crash cart in the exam room for the client to see Instruct client to place feet flat on the floor and lean back to open airway Administer an IM anxiolytic as soon as client is ready Stay with the client, reminding client the panic attack will only last a brief period

Stay with the client, reminding client the panic attack will only last a brief period The priority intervention is to stay with the client and empathize with the client about the symptoms and fear the client is experiencing. A position that would allow more breathing freedom would be to rest hands on knees and lean slightly forward, but this is not the priority option. The crash cart will not reduce the client's anxiety. An anxiolytic agent may be effective but is also not the first priority.

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 action should the nurse institute to help the client be on time for breakfast? Wake the client an hour earlier to perform his ritual. Tell the client to make his bed one time only. Advise the client to have breakfast first before making his bed. Insist that the client stop his activity when it is time for breakfast.

Wake the client an hour earlier to perform his ritual. 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.

A client on the behavioral health unit reports palpitations, trembling, and nausea while traveling alone, outside the home. These symptoms have severely limited the client's ability to function and have caused the client to avoid leaving home whenever possible. The nurse recognizes that this client has symptoms of what disorder? schizoaffective disorder agoraphobia depression generalized anxiety

agoraphobia Agoraphobia is a phobia, or fear, and avoidance of open spaces accompanied by the concern that escape to safety would be difficult or embarrassing. Agoraphobia is commonly accompanied by physical symptoms, such as palpitations, trembling, nausea, and shortness of breath. It is also commonly accompanied or preceded by panic attacks. Thanatophobia is the fear of death; aerophobia, the fear of air; and hodophobia is the fear of traveling.

A nurse refers a client with severe anxiety to a psychiatrist for medication evaluation. The physician is most likely to order which psychotropic drug regimen on a short-term basis? buspirone, 15 mg two times per day 200 mg orally twice per day chlorpromazine, 25 mg orally three times per day alprazolam, 0.25 mg orally every 8 hours benztropine, 2 mg orally twice per day

alprazolam, 0.25 mg orally every 8 hours Alprazolam's antianxiety properties make it the most appropriate medication for this client. It should only be given very short term because of its addictive potential and the client should be weaned off of it. Benztropine is an antiparkinsonian agent used to control the extrapyramidal effects of antipsychotic agents such as chlorpromazine hydrochloride and thioridazine hydrochloride. Chlorpromazine is used to control the severe symptoms (hallucinations, thought disorders, and agitation) seen in clients with psychosis. Buspirone is an antianxiety agent but takes several weeks before it is effective in reducing anxiety. Thus it would not help this client who needs immediate assistance. Alprazolam provides immediate relief.

A nurse notices that a client with obsessive-compulsive disorder washes the hands for long periods each day. How should the nurse respond to this compulsive behavior? by setting aside times during which the client can focus on the behavior by discouraging the client from verbalizing his anxieties by urging the client to reduce the frequency of the behavior as rapidly as possible by calling attention to or trying to prevent the behavior

by setting aside times during which the client can focus on the behavior The nurse should set aside times during which the client is free to focus on the compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. The nurse shouldn't call attention to the behavior or try to prevent it. Trying to prevent the behavior may frighten and hurt the client. The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior.

The nurse is caring for a newly admitted client suspected of having a somatic symptom disorder. The client reports feeling pain in multiple areas. The nurse will conduct what priority assessment? assessment of the client's overall wellness including nutrition, activities of daily living, and rest and sleep assessments of client's self-concept and relationships a thorough mental status exam, including reality testing and compare to client's baseline current assessment findings including a focused assessment on the client's current pain

current assessment findings including a focused assessment on the client's current pain One of the key criteria for the diagnosis of somatic symptom disorder is the absence of clinical or laboratory findings to support any physical manifestations of the described pain. The nurse must be sure that medical causes for the pain have been ruled out and should focus on current findings rather than past ones. Reality testing is not needed at this time as the symptoms of somatic disorders are experienced as real by the client. Assessing self concept and relationships can reveal insight into symptoms and behaviors but it is not definitive for diagnosing a somatic symptom disorder or providing interventions to assist the client. Patterns of sleep, nutrition, and activities of daily living could help determine how well the client is coping with the pain, but is not as important as revealing the reason for the pain at this point.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client is unkempt, has lost approximately 9 lb (4 kg), has been sleeping poorly, and exhibits hyperactivity. The client loudly denies the need for hospitalization. What priority intervention will the nurse apply? decreasing environmental stimulation asking the client to go eat a meal in the day room orientating the client to the unit activities providing adequate hygiene

decreasing environmental stimulation This client is at increased risk for injuring self or others. Decreasing environmental stimulation, a measure the nurse may take independently, may reduce the client's hyperactivity. Providing adequate hygiene is an appropriate nursing intervention but isn't the highest priority. Because the overall goal is to reduce the client's hyperactivity, orientating him to unit activities is contraindicated. Asking the client to go eat a meal in the day room is contraindicated because there is risk for harm to self or others and it is likely there will be more stimulation in the day room.

A client who recently developed paralysis of the arms is diagnosed with functional neurologic symptom disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan for this client? working with the client rather than with the family exercising the client's arms regularly insisting that the client eat without assistance teaching the client how to use nonpharmacologic pain-control methods

exercising the client's arms regularly To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should help the client perform regular passive range-of-motion exercises with the arms. The nurse shouldn't insist that the client use the arms to perform such functions as eating without assistance, because the client can't consciously control the symptoms and move the arms; such insistence may anger the client and endanger the therapeutic relationship. The nurse should include family members in the client's care because they may be contributing to the client's stress or conflict and are essential to helping the client regain function of the arms. The client isn't experiencing pain and, therefore, doesn't need education regarding pain management.

A client diagnosed as having panic disorder with agoraphobia is admitted to the inpatient psychiatric unit. Until admission, the client had been a virtual prisoner at home for 5 weeks, afraid to go outside even to buy food. When planning care for this client, the nurse's overall priority is to help the client: function effectively in the environment. control the client's symptoms. perform self-care activities. participate in group therapy.

function effectively in the environment. A client with panic disorder typically confines movements to increasingly smaller areas to avoid confronting fears that may dominate life and limit everyday activities. The overall goal of care is to help the client function within the environment as effectively as possible. Panic disorder with agoraphobia doesn't impair the ability to perform self-care activities. Controlling symptoms isn't the overall goal; furthermore, helping the client function effectively will help control the symptoms. Although participation in group therapy may help the client control symptoms, encouraging such participation isn't the overall goal of nursing care.

A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when developing the care plan for this client? initially giving the client time to perform rituals and gradually limiting the time immediately interrupt when the client performs rituals and discussing the event after client has calmed instructing the client to notify the nurse when preparing to perform a ritual and praise the client for this effort initially setting strict limits on compulsive behavior and gradually decrease limits

initially giving the client time to perform rituals and gradually limiting the time The nurse should initially give the client time to perform rituals because the client feels this is necessary to reduces anxiety. Interrupting the ritual will cause more anxiety. The nurse will gradually limit the time the client can use to perform the ritual to assist the client to tolerate the thoughts (obsessions) without performing the ritual to reduce anxiety. Setting strict limits and intervening with ritualistic behavior would increase the client's anxiety. Immediately intervening with the clients ritual will cause more anxiety. The goal is for the client to be able to tolerate the thoughts (obsessions) without performing the ritual to reduce the anxiety. It is not realistic for clients to notify the nurse when they are going to perform a ritual.

The client states he washes his feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with which feeling? ambivalence depression irrational fear intolerable anxiety

intolerable anxiety The client with an obsessive-compulsive disorder has an uncontrollable and persistent need to perform behavior that helps relieve intolerable anxiety. In depression, the client feels extreme sadness. Depression is not alleviated by performing obsessive-compulsive actions. Ambivalence refers to two simultaneous opposing feelings. An irrational fear is called a phobia. Phobic behavior is associated with extreme avoidance behavior when confronted with the feared object, not with ritualistic behaviors.

After being examined by a forensic nurse in the emergency department, a rape victim is prepared for discharge. The nurse determines that the client is at risk for posttraumatic stress disorder (PTSD) and teaches the client to recognize symptoms of PTSD. Which symptoms does the nurse include? Select all that apply. sleep disturbances recurrent, intrusive recollections flight of ideas unusual talkativeness difficulty concentrating increased involvement in goal-directed activities

recurrent, intrusive recollections sleep disturbances difficulty concentrating Clients with PTSD typically experience recurrent, intrusive recollections or nightmares, sleep disturbances, difficulty concentrating, chronic anxiety or panic attacks, memory impairment, and feelings of detachment or estrangement that destroy interpersonal relationships. Flight of ideas, increased involvement in activities, and unusual talkativeness are characteristic of the acute manic phase of bipolar disorder.

A nurse assesses a client brought in to the psychiatric unit by family members who believe the client has agoraphobia. The nurse documents which assessment findings as supporting agoraphobia? disorganized and confused thinking causing strange beliefs and withdrawal forgetfulness and an inability to concentrate causing restlessness and impulsivity low self-esteem and feelings of worthlessness causing loss of interest and inactivity severe anxiety and fear causing avoidance of places, people, and situations

severe anxiety and fear causing avoidance of places, people, and situations Agoraphobia is a type of anxiety disorder in which the person has extreme fear and excessive worrying of common daily activities causing the person to avoid going out of their home or to places or situations that they feel they will not be able to escape. Forgetfulness and an inability to concentrate causing restlessness and impulsivity are common in ADHD. Low self-esteem and feelings of worthlessness causing loss of interest and inactivity are common in depression. Disorganized and confused thinking causing strange beliefs and withdrawal occur in schizophrenia.

A client has become increasingly afraid to ride in elevators. While in an elevator one morning, the client experiences shortness of breath, palpitations, dizziness, and trembling. A physician can find no physiological basis for these symptoms and refers the client to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which type of therapy is most likely to reduce the client's anxiety level? psychoanalytically oriented psychotherapy systematic desensitization group psychotherapy referral for evaluation for electroconvulsive therapy

systematic desensitization Phobias are commonly viewed as learned responses to anxiety that can be unlearned through certain techniques such as behavior modification. Systematic desensitization, a form of behavior modification, attempts to reduce anxiety, and thereby eradicate the phobia, through gradual exposure to anxiety-producing stimuli. Psychoanalytically oriented therapy also may be effective in this situation, but years of treatment are required to achieve results. Group psychotherapy could be used as an adjunct treatment to increase the client's self-esteem and reduce generalized anxiety. Electroconvulsive therapy is reserved primarily for clients with severe depression or psychosis who respond poorly to other treatments; it's rarely indicated for phobic disorders.