NSG 374 Chapter 18: Anxiety and Panic Disorders

Which client is most likely to be at risk for drug dependence and difficulties with withdrawal?

A woman who has been taking lorazepam for several months after witnessing a traumatic motor vehicle accident The potential for dependence and difficulties with withdrawal is much higher with benzodiazepines than with beta-blockers or SSRIs.

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

Apprehension Irritability Agitation Withdrawal symptoms manifest in several ways, including psychological phenomena such as apprehension, irritability, and agitation. Withdrawal from benzodiazepines does not cause a sour taste in the mouth. Insomnia would be more likely than hypersomnia.

Which of the following is a behavioral symptom of anxiety?

Avoidance Behavioral symptoms of anxiety include avoidance, restlessness, postural collapse, and hyperventilation. Tremors are a physical symptom of anxiety. Apprehension and impatience are affective symptoms.

A nurse is providing care to a client with a specific phobia. When developing the client's plan of care, which type of therapy would the nurse most likely expect to include as the treatment of choice?

Exposure therapy The client is repeatedly exposed to real or simulated anxiety-provoking situations until he or she becomes desensitized and anxiety subsides. Systematic desensitization exposes the client to a hierarchy of feared situations that the client has rated from least to most feared. Implosive therapy is a provocative technique useful in treating clients with agoraphobia; the therapist identifies phobic stimuli for the client and then presents to the client highly anxiety-provoking imagery, describing the feared scene as dramatically and vividly as possible. Flooding is a technique used to desensitize a client to the fear associated with a particular anxiety-provoking situation. Desensitization is done by presenting feared objects or situations repeatedly without session breaks until the anxiety dissipates.

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

Paroxetine Although other medications may be used to treat panic disorder and other anxiety disorders, the selective serotonin reuptake inhibitors (SSRIs) are recommended as the first drug option in the treatment of clients with panic disorder. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor; imipramine is a tricylic antidepressant; alprazolam is a benzodiazepine.

A client is experiencing a panic attack while in the recreation room. Which intervention would be a priority to promote the client's safety? Select all that apply.

Remaining with the client to assess needs Turning off any televisions or radios in the immediate area During a panic attack, the nurse's first concern is to provide a safe environment. Staying with the client to assess needs is vital. If the environment is overstimulating, the client should move to a less stimulating place. Decreasing external stimuli will help lower the client's anxiety level. An antianxiety agent may be helpful, but it is not the priority; obtaining a prescription would require that the nurse leave the client, which would be inappropriate. Trying to engage the client in recreational activities is likely to exacerbate his or her anxiety.

When developing a plan of care for a client diagnosed with panic disorder, which nursing diagnosis would be considered the priority?

Risk for Self-Directed Violence People with panic disorder are often depressed and consequently are at high risk for suicide. Adolescents with panic disorder may be at higher risk for suicidal thoughts and attempt suicide more often than other adolescents. Other diagnoses that are appropriate for this client population, although not the priority, include Powerlessness, Social Isolation, and Anxiety.

A client is diagnosed with panic disorder. When considering the neurochemical theory of the disorder, which would the nurse expect to administer as the drug of choice initially?

Selective serotonin reuptake inhibitors Serotonin, the indolamine neurotransmitter usually implicated in psychosis and mood disorders. Although antihypertensives and benzodiazepines may be used, the selective serotonin reuptake inhibitors are recommended as the first drug option in the treatment of clients with panic disorder. They have the best safety profile, and if side effects occur, they tend to be present early in treatment before the therapeutic effect takes place. Tricyclic antidepressants are not typically used to treat panic disorder.

According to psychodynamic theorists, anxiety develops from which of the following?

Separation and loss A great number of clients link their initial panic attack with recent personal losses. Classic conditioning theory suggests that one learns a fear response by linking an adverse, or fear-provoking, event with a previously neutral event. Interoceptive conditioning pairs a somatic discomfort, such as dizziness or palpitations, with an impending panic attack. Identification of neurotransmitter involvement in panic disorder has evolved from neurochemical studies with panicogenic substances known to produce panic attacks.

Which condition involves a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger?

Specific phobia Specific phobia is a disorder marked by persistent fear of clearly discernible, circumscribed objects or situations, which often leads to avoidance behaviors. Posttraumatic stress disorder can occur following exposure to an actual or threatened traumatic event such as death, serious injury, or sexual violence. In obsessive-compulsive disorder, affected clients have both obsessions and compulsions and believe that they have no control over them, which results in devastating consequences for the individuals. Generally speaking, clients with generalized anxiety disorder feel frustrated, disgusted with life, demoralized, and hopeless. They may state that they cannot remember a time that they did not feel anxious. They experience a sense of ill-being and uneasiness and a fear of imminent disaster.

When a parent observes the parent's young child heading toward a busy road the parent becomes stressed, feeling the parent's heart pounding, breathing heavily, and hands becoming wet with perspiration. Which physiological system is activated with the parent's "fight or flight" reaction to this danger?

Sympathetic nervous system The sympathetic nervous system activates the fight or flight response quickly as a survival response that results in an increased heart and respiratory rate, moist hands and feet, and dilated pupils. The parasympathetic system is most active in nonstressful events. The motherly instinct is not a proven physiological system.

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called what?

Systematic desensitization One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. Cognitive restructuring involves challenging the client's irrational beliefs. Combination therapy is the use of medications and therapy practice.

A client who experiences panic anxiety around dogs is sitting in a room with a dog and the client's nurse therapist. The nurse therapist is using which behavioral intervention for this type of anxiety?

Systematic desensitization Systematic desensitization refers to the exposure of a person to a fear-producing situation in a systematized manner to decrease a phobic disorder. Implosion therapy, while similar, is not the technique described in this option. This scenario lacks the physical control techniques implemented by relaxation exercise, and it lacks the auditory and/or visual techniques implemented by biofeedback.

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

Tearfulness The clinical symptoms of anxiety are numerous. They are generally classified as physiologic, psychological or emotional, behavioral, and intellectual or cognitive responses to stress. The clinical symptoms may vary according to the level of anxiety exhibited by the client. Tearfulness and sadness are symptoms of depression, not of anxiety.

A client reports the client has been experiencing increased stress at work. The client has been managing the stress by drinking 2-3 glasses of wine per evening. Despite the nurse recommending that drinking alcohol is not an effective way to manage the stress, the client reports it is unlikely that the client will be able to stop. Which statement explains why this will be difficult for the client?

The client has no adaptive coping mechanisms. Clients learn to reduce the anxiety they feel in either functional or dysfunctional ways. The nurse first explores with the client what techniques the client has used in the past and helps the client identify and enhance those strategies that are most beneficial. The nurse and client identify maladaptive coping strategies, such as social withdrawal or alcohol use, and replace them with adaptive strategies that suit the client's personal, cultural, and spiritual values. The nurse should not ask the client to give up coping mechanisms, even maladaptive ones, without offering other adaptive mechanisms.

Which would not be an initial intervention for the client with acute anxiety?

Touching the client in an attempt to comfort the client The nurse should evaluate carefully the use of touch because clients with high anxiety may interpret touch by a stranger as a threat and pull away abruptly. Use open-ended questions, encouraging the client to verbalize feelings and concerns, and maintain a nonstimulating environment.

An adolescent who is seeing the school health nurse states, "I won't be able to hang out with my friends on Friday night because I have two essays due Monday." What level of anxiety is the adolescent experiencing?

mild Mild anxiety is characterized by an increase in sensory stimulation that is helping the adolescent focus attention to achieve a goal. The anxiety is positive because it motivates the adolescent but does not interfere with social, occupational, or emotional functioning. The adolescent is still able to concentrate independently without having to be redirected to the topic. Moderate anxiety is characterized by a disturbing feeling that something is wrong. With moderate anxiety, a person can still process information but may have some trouble with concentration and require redirecting to focus. Severe anxiety is characterized by a significant decrease in a person's cognitive skills. If severe anxiety was being experienced, the adolescent would likely have trouble thinking and reasoning. Panic level of anxiety is characterized by physiological responses to anxiety that take over the ability to reason leading to diminished cognitive skills. It would be nearly impossible for the adolescent to make any decisions about how to organize time to complete homework if panic level of anxiety was being experienced.

The nurse plans to teach a client about dietary modifications to manage diabetes. Teaching would be most effective if the client displayed which characteristic?

Heightened focus Mild anxiety is associated with increased learning ability. It involves a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. Mild anxiety often motivates people to make changes or to engage in goal-directed activity. Focusing only on immediate task, a faster rate of speech, and a narrowed perceptual field are associated with moderate levels of anxiety.

During which type of anxiety does a person's perceptual field actually increase?

Mild During mild anxiety, a person's perceptual field widens slightly, and the person is able to observe more than before and to see relationships. During moderate anxiety, the perceptual field narrows slightly. The person does not notice what goes on peripheral to the immediate focus but can do so if attention is directed there by another observer. The perceptual field is greatly reduced in severe anxiety. During panic anxiety, the perceptual field is reduced to a detail, which is usually "blown up."

Anxiety has both healthy and harmful aspects depending on its degree and duration as well as on how well the person copes with it. Which level of anxiety helps the client focus attention to learn, problem solve, think, act, feel, and protect himself or herself?

Mild In mild anxiety, sensory stimulation increases and helps the person focus attention to learn, solve problems, and think. Moderate anxiety causes the person to have difficulty concentrating independently but can be redirected to the topic. Severe anxiety causes the person to have a reduced perceptual field, and he or she cannot complete tasks. Panic anxiety reduces the perceptual field to focus on the self, and the client cannot process any environmental stimuli.

A nurse seems nervous and distracted before giving a presentation. The nurse is watching the guest speaker and occasionally reviewing note cards. When the guest speaker asks a question of the group, the nurse answers correctly in a high-pitched voice. The nurse is most likely demonstrating which degree of anxiety?

Moderate Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic. Mild anxiety is a sensation that something is different and warrants special attention, but would not likely lead to distraction.As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning. A person who is in panic appears out of control.

A nurse is working with a client who is learning to cope with anxiety and stress. What outcome does the nurse expect for the client?

Reactions to stressors will change Stress and anxiety in life are unavoidable; managing the effects of stress is a reasonable goal for treatment. It is not possible or desirable to avoid anxiety at all costs as anxiety is a warning that the client is not dealing with stress effectively. Learning to heed this warning and to make needed changes is a healthy way to deal with the stress of daily events.Healthy stress management does not involve "ignoring" stressors. Limiting the presence of stressors does not necessarily increase the client's ability to cope with existing stressors.

A client says to the nurse, "I just can't talk in front of the group. I'm trembling and I feel like I'm going to pass out." The nurse assesses the client's anxiety to be at which level?

Severe Physiologic responses to severe anxiety include headache, nausea, vomiting, diarrhea, trembling, rigid stance, vertigo, pale, tachycardia, and chest pain. Vetigo can cause a sensation of "passing out." A client who is panicking would not be able to articulate his or her state.

A nurse is conducting a seminar for a group of individuals at the community center about anxiety. The nurse determines that the seminar was successful based on which group statement?

"Anxiety cannot be completely eliminated from life." Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. Anxiety is unavoidable in life and can serve many positive functions, such as motivating the person to take action to solve a problem or to resolve a crisis.

The nurse is providing care for a psychiatric-mental health client who has a diagnosis of anxiety. Which statement by the nurse is likely the most therapeutic intervention?

"Anxiety is a feeling that is experienced by everyone at some point and it can never be completely removed from one's life." It is therapeutic to foster in clients the understanding that the experience of anxiety is natural and inevitable. It would be inaccurate to promise recovery with increased success in life and self-discipline. Clients with anxiety are likely to be well aware of how much easier their lives would be without recurring anxiety.

A client asks the nurse, "Why do I have to go to counseling? Why can't I just take medications?" What would be the most appropriate response by the nurse?

"Medications combined with therapy help you change how well you function." Treatment for anxiety disorders usually involves medication and therapy. This combination produces better results than either one alone. These interventions complement one another and are not mutually exclusive. The effectiveness of medications is not wholly dependent on cognitive therapy.

An anxiolytic agent, lorazepam, has been prescribed for the client. Which statement by the client would indicate to the nurse that client education about this medication has been effective?

"This medication will relax me, so I can focus on problem solving." Anxiolytics are designed for short-term use to relieve anxiety. These drugs are designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress. Benzodiazepines have a tendency to cause dependence. Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety but do not treat the underlying problems that cause the anxiety.

Which statement, made by a client diagnosed with an anxiety disorder, should trigger the nurse's concern about the client's understanding of the use of defense mechanisms?

"When I have a problem, I just deny it until it goes away." The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. Denial should not be used to deal with all of one's problems. None of the remaining options present untrue or troubling statements regarding defense mechanisms.

A client is currently experiencing a panic attack. Which is the most appropriate response by the nurse?

"You are safe. Take a deep breath." Saying "You are safe. Take a deep breath" reassures and redirects the client. Telling the client to relax is simplistic and ineffective. The nurse should follow reassurance ("There is nothing here to harm you") with redirection. Asking the client to describe his or her feelings does not provide reassurance or redirection.

The nurse recognizes that who is the client most likely experiencing generalized anxiety disorder (GAD)?

40-year-old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months

A patient with anxiety disorder has excessive anxiety and worries about multiple life circumstances. For how long would this patient experience these feelings before the anxiety disorder would be considered chronic and generalized?

6 months For generalized anxiety disorder, the diagnostic criteria listed include unrealistic or excessive anxiety and worry about two or more life circumstances for 6 months or more, during which time these concerns exist for a majority of days.

What does desensitization refer to?

A systematic way to replace a panic response with a relaxation response Systematic desensitization is a classical conditioning technique by which a client learns to replace gradually a panic response with a relaxation response. It is a behavioral therapy used to treat specific phobias, social phobias, agoraphobia, and posttraumatic stress disorder. The client progressively confronts the object of fear in very small, controlled steps while in a deeply relaxed state.

A client approaches the nurse on an inpatient psychiatric hospital unit crying, trembling, and feeling nauseous. The client states, "I've tried everything, I still feel so anxious." Which action by the nurse would be most appropriate?

Administer the prescribed PRN anxiolytic medication. The client is experiencing severe anxiety. The client tells the nurse the client has tried other strategies but they have not been effective. Given the client's report of symptoms, it would be appropriate to administer a dose of the prescribed PRN anxiolytic medication. Once the client is experiencing a decrease in the uncomfortable physiologic symptoms associated with the severe anxiety, it will be easier to engage the client in nonpharmacological interventions, such as deep breathing, to manage any residual signs and symptoms of the anxiety.

A client is currently experiencing panic. Which action would be most appropriate for the nurse to do?

Allow the client to pace With panic, the nurse should stay with the client. Allow pacing and walk with the client. No content inputs to the client's thinking should be made by the nurse. Asking repeated questions and teaching would be inappropriate because the client is already over-stressed. The client should use positive self-talk. Encouraging vigorous exercise would increase the physiological arousal associated with panic and should be avoided until the client is calm. Exercise should be encouraged for prevention and to promote mental wellness.

Panic disorder is treated with cognitive-behavioral techniques and deep breathing and relaxation, in addition to which of the following?

Antianxiety medications / antidepressants such as benzodiazepines, SSRIs, tricyclics, and antihypertensives, such as Catapres and Inderal or clonidine and propranolol.

The mental health nurse knows that which medication classification has been found to be effective in reducing or eliminating panic attacks?

Antidepressants Tricyclic and monoamine oxidase inhibitor antidepressants have been found to be effective in treating clients with panic attacks. Why these drugs help control panic attacks is not clearly understood. Anticholinergic agents, which are smooth-muscle relaxants, relieve physical symptoms of anxiety but do not relieve the anxiety itself. Antipsychotic drugs are inappropriate because clients who experience panic attacks are not psychotic. Mood stabilizers are not indicated because panic attacks are rarely associated with mood changes.

Clients taking benzodiazepines need education about what?

Concomitant use of alcohol Benzodiazepines have long been the drugs of choice for treatment of anxiety disorders. They can induce a physical dependence and can induce severe withdrawal symptoms and intense rebound anxiety when discontinued abruptly. They potentiate the effects of alcohol and other sedative hypnotics, are commonly abused, and have several significant side effects. The most common adverse effects are sedation, ataxia, loss of coordination, slurred speech, memory impairment, paradoxical agitation, and dizziness. They also cause psychomotor impairment.

The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which in the discharge teaching? Select all that apply.

Continued development of positive coping skills Continued practice of relaxation techniques Development of a regular exercise program client/family education for panic disorder includes reviewing breathing control and relaxation techniques, discussing positive coping strategies, encouraging regular exercise. Medication should be adhered to as prescribed; the client may or may not be instructed to wean off of medications. Daily responsibilities cannot be avoided, but rather should be successfully accomplished.

The client has been defensive toward communication with the nurse today. Which can be a positive outcome of using defense mechanisms?

Defense mechanisms can help a person to reduce anxiety. Defense mechanisms can help a person to reduce anxiety. This is the only positive outcome of using defense mechanisms. Overdependence on defense mechanisms can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. These are all negative outcomes of using defense mechanisms.

A client is experiencing a panic attack. Which term describes sensing that things are not real?

Derealization Derealization is sensing that things are not real. Automatisms are automatic, unconscious mannerisms. Depersonalization describes feelings of being disconnected from oneself, as seen in a panic attack. Agoraphobia is a fear of being outside.

When assessing an elderly client who has newly been diagnosed with an anxiety disorder, the mental health nurse's priority is to carry out which task?

Determine the client's risk for self-harm or harm to others The first step in the assessment process is to identify the client's level of anxiety and to determine whether a threat of self-harm or harm to others exists. In any situation where the client history is not known, the nursing priority is safety.

A nurse is assessing a client and determines that the client is experiencing severe anxiety based on which finding?

Distorted sensory awareness In severe anxiety, perception becomes increasingly distorted, sensory input diminishes, and processing of sensory stimuli becomes scattered and disorganized.

In teaching a client who has been prescribed a benzodiazepine for panic disorder, the nurse must be certain to do what?

Educate the client that this medication has a high risk for withdrawal symptoms, and the client should not discontinue without a doctor's supervision. The benzodiazepines have a high risk for withdrawal symptoms, and the client needs to be educated as to this fact. The benzodiazepines do not interact with certain food groups like monoamine oxidase inhibitors do. The client does not need to have blood drawn when being treated with benzodiazepines; this would be true if the client were on an atypical antipsychotic such as clozapine. There is no risk for dysrhythmias with the benzodiazepines.

A client states that the client has just had an argument with the client's spouse over the phone. What can the nurse expect that the client's sympathetic nervous system has stimulated the client's adrenal gland to release?

Epinephrine In the sympathetic-adrenal-medullary response to stress, the sympathetic nervous system stimulates the adrenal gland to release epinephrine and norepinephrine. Corticotropin-releasing factor, adrenocorticotropic hormone (ACTH), and glucocorticoids are released in the hypothalamic-pituitary response to stress.

Nursing interventions for physical stress related illness should include what?

Establishing daily routines of meals and sleeping Individuals experiencing or at risk for untoward stress responses may benefit from a number of biologic interventions. The importance of (re-)establishing regular routines for activities of daily living (e.g., eating, sleeping, self-care, and leisure time) cannot be overstated. As well as ensuring adequate nutrition, sleep and rest, and hygiene, a routine may help to structure an individual's time and give them a sense of personal control or mastery.

Generalized anxiety disorder (GAD) is characterized by what criteria?

Excessive worry or anxiety lasting more than 6 months GAD is usually characterized by chronic and excessive worry and anxiety more days than not, occurring for at least 6 months and involving many aspects of the person's life.

Which is one characteristic that differentiates generalized anxiety disorder (GAD) and panic disorder?

In GAD, the person usually does not experience eruptions of acute anxiety. GAD is characterized by the pervasive existence of severe anxiety with no apparent cause. Panic disorder is characterized by acute onset of panic levels of anxiety.

The nurse can document correctly that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client doing what?

Pacing and repeatedly asking staff what time the "doctor will be here." The nurse documents that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client pacing and repeatedly asking staff members when the doctor will arrive. Moderate anxiety is characterized by wandering attention. The client may require repeated redirection, such as in this scenario.

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

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

A nurse is assessing a client and notes that the client is exhibiting affective mainfestations of anxiety. Which manifestation would the nurse most likely assess?

Irritability Affective signs and symptoms to assess for include irritable, worried, tense, or fearful affect; feelings of helplessness or inadequacy; and overly excited, wary, or anguished affect.

Which medication classification has most commonly been used to treat social phobia?

Selective serotonin reuptake inhibitors (SSRIs) SSRIs are used to treat clients with social anxiety disorder because they significantly reduce social anxiety and phobic avoidance. Benzodiazepines are also used to reduce anxiety caused by phobias.

A nurse assesses a client and determines that the client is experiencing mild anxiety based on what?

The client is aware and alert A client who is mildly anxious is aware, alert, sees, hears, and grasps more than before. Selective inattention reflects moderate anxiety. Focusing attention on a small area reflects severe anxiety. Feelings of unreality are associated with panic.

Which of the following is inconsistent with panic-level anxiety?

This level of anxiety can be sustained indefinitely. Panic-level anxiety cannot be sustained indefinitely. The nurse should remain with the client until the panic recedes and should maintain a nonstimulating environment. The goal is to the lower the client's anxiety to mild or moderate before proceeding with anything else.

After teaching a group of mental health nursing students about the care of a client experiencing a panic attack, the instructor determines that additional education is required when the students identify which as an appropriate intervention?

Touching the client in an attempt to comfort the client For the client experiencing a panic attack, the nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety. Trust can be established by approaching the client in a calm and confident manner; providing a place that is quiet, safe, and private; and encouraging the client to verbalize feelings and concerns.

A nurse is preparing a plan of care for a client with anxiety. Which elements would the nurse likely include? Select all that apply.

Using appropriate coping skills Identifying treatment modalities Involving family for support, if appropriate Providing supportive feedback Appropriate measures to include in the plan of care for a client with anxiety include: introducing appropriate coping skills, identifying alternate treatment modalities, involving family and support persons when appropriate, and providing feedback that is supportive to the client. Restraint is always a last resort.

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

Venlafaxine Venlafaxine (Effexor) is the most commonly used SNRI. Duloxetine is a SNRI however, it is not the most commonly prescribed drug of this class. Paroxetine and fluoxetine are selective serotonin reuptake inhibitors.

A psychiatric nurse visits a client at home. The client tells the nurse that he or she experiences chest pain, shortness of breath, and sweating whenever leaving home. The client has been unable to go to work for six weeks. The nurse recognizes this problem as which behavior?

agoraphobia Agoraphobia refers to the client's fear of open spaces, which would be faced whenever the client leaves home. The other three options are specific phobias: mysophobia refers to fear of dirt or germs; claustrophobia refers to fear of closed spaces; and acrophobia refers to fear of heights.

After a client has been prescribed on fluoxetine (Prozac) for a diagnosis of anxiety disorder, which of the following information should the nurse be sure to include in the client teaching?

sometimes in the first week of treatment, the client may experience heightened feelings of anxiety, but these will pass when you become accustomed to the new medication. Prozac and other SSRIs may take 2 weeks or longer to build to therapeutic levels with maximum effectiveness.