Anxiety and Obsessive compulsive disorder
A patient who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." A helpful response for the nurse to make would be "Let's try to focus on that adorable little granddaughter of yours." "Why don't you sit down over there and work on that jigsaw puzzle?" "Try not to think about the feelings and sensations you're experiencing." "What things have you done in the past that helped you feel more comfortable?"
"What things have you done in the past that helped you feel more comfortable?" Because the patient is not able to think through the problem and arrive at an action that would lower anxiety, the nurse can assist by asking what has worked in the past. Often what has been helpful in the past can be used again. p. 285, Table 15.9
An obsession is defined as A recurrent, persistent thought or impulse An intense irrational fear of an object or situation A recurrent behavior performed in the same manner Thinking of an action and immediately taking the action
A recurrent, persistent thought or impulse bsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. p. 278
A patient just learned that a family member was diagnosed with a serious illness. At this time, the patient is pacing, distracted, breathing rapidly, complaining of nausea, and having trouble focusing on anything other than the family member's illness. Which initial nursing comment is most therapeutic? "You seem anxious. Would you like to talk about how you are feeling?" "You cannot help the other members of your family if you do not calm down." Address the patient by name and say, "You are safe. First, take a deep breath." "There are always specialists who can help. Try not to worry about your loved one."
Address the patient by name and say, "You are safe. First, take a deep breath." This patient is experiencing severe anxiety, so the perceptual field is reduced greatly. The person may be dazed and confused. Behavior is automatic and usually includes somatic symptoms (e.g., headache, nausea, dizziness, insomnia, trembling, hyperventilation, palpitations). Appropriate nursing interventions are to provide for safety and offer firm, short, and simple statements. When the person's anxiety level lowers, feelings can be explored. Threats to calm down and false reassurance are not therapeutic and will be ineffective during this level of anxiety. p. 286, Table 15.10
A patient is fearful of riding in elevators and always takes the stairs. Which brain structure is involved in this fear and behavior? Thalamus Amygdala Hypothalamus Pituitary gland
Amygdala The amygdala plays a role in anxiety disorders. It alerts the brain to the presence of danger and brings about fear or anxiety to preserve the system. Memories with emotional significance are stored in the amygdala and are implicated in phobic responses. The thalamus relays sensory information to other brain centers. The hypothalamus is involved in regulation of the autonomic nervous system. The pituitary gland secretes regulatory hormones. p. 281
What is included in the nursing plan of care for a patient diagnosed with anxiety who is exhibiting severe hyperactivity? Place the patient in seclusion. Attend to the patient's physical needs. Help the patient identify the source of anxiety. Communicate using simple, loud, clear statements.
Attend to the patient's physical needs. The nursing care plan for a patient diagnosed with anxiety who is exhibiting severe hyperactivity is to attend to the patient's physical needs. Severe hyperactivity is characteristic of a panic level of anxiety and attending to physical needs such as elimination, fluids, and nutrition are important. Seclusion should be initiated after all other interventions have been tried and are unsuccessful. Helping a patient identify the source of anxiety is more effective for a patient experiencing mild to moderate anxiety. When the nurse is communicating with a patient experiencing severe anxiety, a low-pitched voice should be used.
A patient is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the patient reports Repeatedly verbalizing prayers helps the patient feel relaxed That eating in public makes the patient extremely uncomfortable That the symptoms started right after the patient was robbed at gunpoint Being so worried the patient hasn't been able to work for the last 12 months
Being so worried the patient hasn't been able to work for the last 12 months GAD is characterized by symptomology that lasts six months or longer. p. 277
Working to help the patient view an occurrence in a more positive light is called Flooding Desensitization Response prevention Cognitive restructuring
Cognitive restructuring The purpose of cognitive restructuring is to change the individual's negative view of an event or a situation to a view that remains consistent with the facts but that is more positive. p. 276
A patient counts everything; for example, the patient counts the number of steps to the bathroom, rings of the telephone, and cups in the pantry. How should the nurse document this finding? Phobia Obsession Compulsion Trichotillomania
Compulsion Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety or prevent an imagined calamity. Performing the compulsive act temporarily reduces anxiety, but because the relief is only temporary, the compulsive act must be repeated again and again. A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance, of the object, activity, or situation. Obsessions are thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind even though the individual attempts to do so. Obsessions often seem senseless to the individual who experiences them (ego-dystonic), and their presence causes severe anxiety. Trichotillomania refers to hair pulling disorder. p. 278
A man continues to speak of his wife as though she were still alive, three years after her death. This behavior suggests the use of Altruism Denial Undoing Suppression
Denial Denial involves escaping unpleasant reality by ignoring its existence. p. 274
The primary purpose of performing a physical examination before beginning treatment for any anxiety disorder is to Protect the nurse legally Establish the nursing diagnoses of priority Obtain information about the patient's psychosocial background Determine whether the anxiety is primary or secondary in origin
Determine whether the anxiety is primary or secondary in origin The symptoms of anxiety can be caused by a number of physical disorders or are said to be caused by an underlying physical disorder. The treatment for secondary anxiety is treatment of the underlying cause. p. 281
A patient is experiencing a panic attack. The nurse can be most therapeutic by Encouraging the patient to take slow, deep breaths Verbalizing mild disapproval of the anxious behavior Offering an explanation about why the symptoms are occurring Asking the patient what he or she means when he or she says, "I am dying."
Encouraging the patient to take slow, deep breaths Slow diaphragmatic breathing can induce relaxation and reduce symptoms of anxiety. Often the nurse has to tell the patient to "breathe with me" and keep the patient focused on the task. The slower breathing also reduces the threat of hypercapnia with its attendant symptoms. p. 276, Table 15.4
A symptom commonly associated with panic attacks is Obsessions Apathy Fever Fear of impending doom
Fear of impending doom The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is limited severely, and misinterpretation of reality may occur. p. 276
A patient diagnosed with panic disorder is prescribed chlordiazepoxide. What is the most appropriate suggestion by the nurse? Follow contraceptive methods. Stop the medication after 3 months. Change the medication if there is insomnia. Coffee and tea are fine to drink and won't interact with the medication.
Follow contraceptive methods Chlordiazepoxide belongs to the benzodiazepine class of antianxiety drugs. It causes congenital anomalies in the fetus; therefore, the patient should avoid becoming pregnant. As caffeine decreases the efficacy of the benzodiazepines, the nurse should suggest the patient avoid drinking coffee and tea. The nurse should suggest continuing medication after 3 to 4 months. Abruptly stopping the medication can cause withdrawal symptoms like dry mouth, tremors, and convulsions. p. 288
To support best improvement in an anxious individual's sense of control and competence, the nurse: Provides lavish amounts of praise when the individual accomplishes assigned tasks. Educates the individual regarding the usefulness of stress management techniques. Helps the individual identify several stress situations that he or she was successful in managing. Has the individual describe how one demonstrates control and competence over stress.
Helps the individual identify several stress situations that he or she was successful in managing. Positive self-concepts result from positive experiences, leading to perceived competence and acceptance. Assisting the patient in identifying such situations will aid in building confidence and one's perception of being competent. Being praised for successes is appropriate, but it must be reserved for situations that the individual recognizes as meaningful. Although stress management techniques are important, they are not linked directly to a sense of competence. Describing how one demonstrates control and competence is applicable but it has limited favor in actually assisting the patient in feeling competent. p. 285
If the record mentions that the patient habitually relies on rationalization, the nurse might expect the patient to Miss appointments Make jokes to relieve tension Justify illogical ideas and feelings Behave in ways that are the opposite of his or her feelings
Justify illogical ideas and feelings Rationalization involves justifying illogical or unreasonable ideas or feelings by developing logical explanations that satisfy the teller and the listener. p. 274, Table 15.2
Which therapeutic intervention can the nurse implement personally to help a patient diagnosed with a mild anxiety disorder regain control? Flooding Modeling Thought stopping Systematic desensitization
Modeling Modeling calm behavior in the face of anxiety or unafraid behavior in the presence of a feared stimulus are interventions that can be used independently. Flooding, thought stopping, and systematic desensitization require agreement of the treatment team. p. 285
A young adult invites eight people to dinner. This person has never given a dinner party and wants to prepare every menu item. On the morning of the party, the young adult multitasks and makes progress preparing each food item. As the time approaches for the guests to arrive, which change indicates an increased anxiety level? Muscles become tense. The person must stop cooking to use the bathroom every 10 to 15 minutes. Blood pressure and pulse rates increase slightly. The person notices feelings of mild muscle tension. Fond memories of family reunions and the good food that was served drift in and out of the person's thoughts. The person notices there are cobwebs in the corner of the dining room and removes them before the guests arrive.
Muscles become tense. The person must stop cooking to use the bathroom every 10 to 15 minutes. Normal responses to stress and activation of the sympathetic nervous system include muscle tension and frequency or urgency of urination. Other observable symptoms are fine hand tremors, restlessness, nervousness, inability to concentrate, flushing, and sweating. p. 271
The inability to leave one's home because of avoidance of severe anxiety suggests the anxiety disorder of Generalized anxiety disorder Posttraumatic stress response Panic attacks with agoraphobia Obsessive-compulsive disorder
Panic attacks with agoraphobia Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred. p. 277
An adult states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems okay except for these times, but it's affecting my ability to go to work." This information supports which psychiatric diagnosis? Agoraphobia Panic disorder Social anxiety disorder Separation anxiety disorder
Separation anxiety disorder People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other. There also may be fear that something horrible will happen to the other person. Adult separation anxiety disorder may begin in childhood or adulthood. The scenario doesn't describe panic disorder. Agoraphobia is characterized by intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. p. 273
Prior to transferring a patient for a scheduled procedure, the patient tells the nurse, "I feel like I am going to die." Based on the statement the patient made, what level of anxiety is the patient experiencing? Mild Panic Severe Moderate
Severe The patient is experiencing severe anxiety, which is associated with a sense of impending doom. A patient experiencing panic may have anxiety so severe that he or she is unable to communicate. Moderate anxiety is characterized by findings that include tension behavior, poor concentration, and voice tremors. Characteristics of mild anxiety include restlessness, irritability, and impatience. p. 272
A patient frantically reports to the nurse "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the patient's level of anxiety as Mild Panic Severe Moderate
Severe Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart. p. 272
A patient attempted suicide three days ago. When the nurse asks about the related events, the patient says, "I don't want to think about that now, but maybe we could talk about it later." Which defense mechanism has the patient used? Repression Suppression Rationalization Intellectualization
Suppression Defenses against anxiety can be adaptive or maladaptive. Suppression is a conscious, deliberate effort to avoid painful and anxiety-producing memories. Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. In this scenario, the patient is aware of the memory. Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations. Intellectualization is a process in which events are analyzed based on facts and without passion, rather than including feeling and emotion. p. 274, Table 15.2
When prescribed lorazepam 1 mg orally, four times a day, for one week, for generalized anxiety disorder, the nurse should Tell the patient to expect mild insomnia Teach the patient to limit caffeine intake Explain the long-term nature of benzodiazepine therapy Question the health care provider's prescription because the dose is excessive
Teach the patient to limit caffeine intake Caffeine is an antagonist of antianxiety medication. p. 288
A 3-year-old child is admitted for an extensive stay in an acute care hospital. The parents will be able to visit only on weekends. The nurse bases emotional care of the child on the understanding that Children are emotionally resilient at this age The nursing staff can act as effective substitutes for the child's parents The child is at risk for physical illnesses resulting from the separation Providing appropriate stimulating activities will minimize the child's stress-related risks
The child is at risk for physical illnesses resulting from the separation Children who have been separated from their mothers, especially if placed in an impersonal environment, show a decline in physical health. Resiliency will not be sufficient to overcome the effects of separation from parents. The nursing staff may attempt to be substitutes for the parents, but at this age, the child will be aware of the separation and experience the negative effects. Stimulation will address cognitive and development needs but not emotional ones. p. 273
A patient with obsessive-compulsive disorder takes several hours to maintain hygiene. What appropriate method does the nurse follow to help the patient in maintaining hygiene? The nurse dresses the patient. The nurse talks about self-care with the patient. The nurse gives continuous directions to the patient. The nurse gives a wide variety of clothing options to the patient.
The nurse talks about self-care with the patient. Patients with obsessive-compulsive disorder spend several hours maintaining hygiene. The nurse should talk with patients regarding self-care and encourage them to express their feelings and thoughts about self-care, as it can help reduce the compulsive behavior. Limiting the choice of clothing helps the patient to select clothes quickly. The nurse gives simple directions to the patient to enhance self-hygiene. The nurse should not dress the patient but can assist the patient in dressing. The nurse should encourage the patients to perform the task independently. p. 287
A nurse observes a patient's parents at an intensive care unit. The nurse assumes that the patient's parents have moderate anxiety. Which symptom of anxiety did the nurse find in the patient's parents? The parents were talking in a trembling voice. The parents were having increased rate of respiration. The mother is tapping her foot and the father is chewing his lip. The parents were confused and unable to make any decisions. The parents were making decisions to solve the problem very effectively.
The parents were talking in a trembling voice. The parents were having increased rate of respiration. People having moderate anxiety have voice tremors and tend to talk in a trembling voice. They show increased pulse rate and respiratory rate. They also cannot make decisions to solve the problem at an optimum level. People with mild anxiety exhibit mild tension-relieving behavior such as foot or finger tapping and lip chewing. In severe anxiety, people are usually confused and are unable to make decisions. p. 284
A student nurse observes that a patient often looks at her reflection in the mirror. What is the most appropriate diagnosis the student nurse could make from the patient's behavior? The patient has panic disorder. The patient has hoarding disorder. The patient has body dysmorphic disorder. The patient has obsessive-compulsive disorder.
The patient has body dysmorphic disorder. Dysmorphic disorders are characterized by a preoccupation with an imagined defective body part. Dysmorphic patients often pay excessive attention to body parts that they imagine to be defective. As a result, they may develop obsessive-compulsive behaviors such as often checking the mirrors. In obsessive-compulsive disorder patients perform repeated activities or rituals. In hoarding disorder the patient accumulates and collects all materials for future use. Patients with panic disorder may have an unusual fear of future events. p. 280
A nurse observes a patient who often pulls out his or her hair. What appropriate condition does the nurse report to the primary health care provider based on this observation? The patient has trichorrhexis. The patient has trichophagia. The patient has trichotillomania. The patient has Rapunzel syndrome.
The patient has trichotillomania. Psychiatric patients often pull out hair to relieve stress. This condition is called trichomoniasis. Trichorrhexis is a defect in the hair shaft where the hair becomes thin and breaks off easily. Patients who secretly swallow the pulled hair have a condition called trichophagia. The masses of hair present in the stomach are referred to as Rapunzel syndrome. pp. 280, 281
In a teaching session, the nurse uses strategies that would induce a slight degree of anxiety in the patients attending the session. What is the nurse's intention for this action? The patients would be more focused during the session. The patients would be more expressive during the session. The patients would be more comfortable during the session. The patients would be more willing to participate in the session.
The patients would be more focused during the session. Mild anxiety causes patients to see, listen, and grasp more information. This helps the patients to focus more on whatever is taught during the teaching session. Mild anxiety is unlikely to improve the patient's expression, comfort level, or willingness to participate. The nurse should involve the patient in discussion so that the patient expresses his or her feelings and should modify the environment of teaching to make the patient comfortable. p. 271
What characteristics are associated with moderate anxiety? The person engages in selective inattention. Learning and problem solving are no longer possible. People routinely describe a feeling of "impending doom." Gastric discomfort and headaches sometimes are reported. The sympathetic nervous system begins to control vital signs.
The person engages in selective inattention. Gastric discomfort and headaches sometimes are reported. The sympathetic nervous system begins to control vital signs. The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out. Sympathetic nervous system symptoms begin to kick in. The individual may experience tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency). The ability to think clearly is hampered, but learning and problem solving can still take place, although not at an optimal level. A feeling of impending doom is associated with severe anxiety. pp. 271, 272
A 72-year-old patient is diagnosed with Parkinson's disease and anxiety. The health care provider prescribes a benzodiazepine. The nurse questions this prescription based on what fact related to this classification of medications? This medication would increase the patient's risk for falls. Older adults become addicted faster than younger patients. Benzodiazepines have serious side effects, so patients are often noncompliant. Cognitive therapies rather than medication are more effective for the older patient.
This medication would increase the patient's risk for falls. An important nursing intervention is to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. In a patient who has a history of falls, lorazepam would be contraindicated because it may cause sedation and ataxia, leading to more falls. There is no evidence to suggest that elderly patients become addicted faster than younger patients. This classification of medications generally is not associated with nonadherence and would not lead one to question this drug prescription. Medication and other therapies are used congruently with all age levels. p. 288
