Mental Health Ch. 9

Which communication techniques should the nurse use with a client who has been identified as having difficulty expressing thoughts and feelings? Using emotionally charged words and gestures Offering opinions and avoiding periods of silence Asking closed-ended questions requiring "yes" or "no" answers Asking open-ended questions and seeking clarification

Asking open-ended questions and seeking clarification Open-ended questions give the client the widest possible latitude in answering. Also, the client can take the lead in the interview. Seeking clarification helps the client clarify his or her own thoughts and promotes mutual understanding.

Two main principles that can guide the communication process during the nurse-client interview are clarity and giving recognition. personal and environmental factors. passive listening and cultural caution. interpreting and speculating on the client's meaning.

clarity and giving recognition. Clarity refers to mutual understanding of communication, and giving recognition indicates awareness of change and personal efforts. Both are desirable.

The content and direction of the clinical interview is determined by the nurse. client. physician. health care team.

client. The client always takes the lead and determines the content and direction of the clinical interview, although the nurse may discourage social conversation or intrusive personal questioning.

Recent immigrants to the United States from which country would find direct eye contact a positive therapeutic technique? Korea Mexico Japan Germany

Germany Eye contact conveys interest to most northern European individuals. Eye contact would be considered intrusive to the others.

What is the most helpful nursing response to a client who reports thinking of dropping out of college because it is too stressful? "Don't let them beat you! Fight back!" "School is stressful. What do you find most stressful?" "I know just what you are going through. The stress is terrible." "You have only two more semesters. You will be glad if you stick it out."

"School is stressful. What do you find most stressful?" This response acknowledges the speaker's perception of school as difficult and asks for further information. This response suggests the nurse is listening actively and is concerned.

Which statement by the nurse reflects the process occurring in the clinical interview? "Give me an example of something your wife does that 'drives you nuts.'" "What makes you think your doctor will give you a pass?" "When is your child custody hearing going to be held?" "You are frowning. What are you feeling?"

"You are frowning. What are you feeling?" Process refers to nonverbal behavior. Nonverbal behavior is often a more accurate gauge of client feelings than what is being verbalized.

When interacting with a patient, what nonverbal communication can be observed that would lead the nurse to believe the patient is sad? 1 Eye expressions 2 Hand gestures 3 Manner of dress 4 Body posture

1 A study reports that the nurse can easily identify the feelings of sadness in the patient using eye expressions. Hand gestures are more helpful to the nurse in interpreting feelings of tension in patient. Based on the patient's clothes and manner of dress, the nurse can assess the ability of the patient to perform self-care activities. The patient's body posture helps the nurse to assess the attentiveness of the patient.

Which nursing intervention best builds a therapeutic nurse-patient relationship? 1 Actively listening as the patient expresses his or her thoughts and feelings. 2 Intervening when the patient begins to state beliefs that come from his or her illness. 3 Evaluating a patient's behaviors and interpersonal relationships frequently to identify stressors. 4 Passively allowing the patient to control the communication and tone of the discussions.

1 An effective nurse-patient relationship is built upon communication that encourages and respects varying points of view in a nonjudgmental atmosphere. Challenging beliefs and values is not appropriate until the relationship is well established. Evaluating a patient's behaviors and interpersonal relationships frequently to identify stressors is not an initial goal when attempts are being made to establish a therapeutic nurse-patient relationship. Although the nurse encourages the patient to communicate in an honest, unrestricted manner, a passive approach on the nurse's part would not be therapeutic.

What is the focus during clinical supervision? 1 The nurse's behavior in the nurse-patient relationship 2 Analysis of the patient's motivation for transferences 3 Devising alternative strategies for patient growth 4 Assisting the patient to develop increased independence

1 Clinical supervision helps the nurse look at his or her own behavior and determine more effective approaches to working with patients.

A nurse is interacting with a child during a home visit. The nurse learns that the child is depressed because he scored low on an exam. By the nurse's response, the child felt that the nurse is unable to understand the feeling. Which nontherapeutic response might the nurse have used? 1 "Why did you score low in your exams?" 2 "What are you worried about?" 3 "You must be feeling very upset." 4 "What would you like to talk about?"

1 The response, "Why did you score low on your exams?" is a nontherapeutic response because it makes the child inferior for scoring low. The child can feel that the nurse is unable to understand his feelings. The response, "What are you worried about?" is a therapeutic response. The child feels that the nurse is able to understand and acknowledge his feelings. The response, "You must be feeling very upset" is a therapeutic response. It is an example of reflecting, in which the nurse has stated the child's feelings to seek clarification. The response, "What would you like to talk about?" is a therapeutic response. It is an example of broad opening in which the nurse encourages the child to share his feelings.

Which statement determines that the nurse understands the issues surrounding the use of therapeutic touch? Select all that apply. 1 "Would it be a comfort to you if I held your hand during this procedure?" 2 "Does this facility have a "no touch" policy when caring for sexually abused patients?" 3 "As nurses we understand that not all members of a culture share similar feelings about being touched." 4 "It is my understanding that as a culture, Hispanics are usually comfortable with appropriate touch." 5 "Personal touch generally brings about similar feelings as does therapeutic touch among most patients."

1,2,3,4 The therapeutic use of touch is a basic aspect of the nurse-patient relationship and generally is considered a gesture of warmth and friendship; however, the degree to which a patient is comfortable with the use of touch often is determined culturally. People from some cultures, Hispanic for example, are accustomed to frequent physical contact. However, personal touch within the context of an interview may be perceived as an invasion of privacy or experienced as patronizing, intrusive, aggressive, or sexually inviting in other cultures. Even among people from similar cultures, the use of touch has different interpretations and rules regarding gender and class. Some facilities have a "no touch" policy, particularly with adolescents and children who have experienced inappropriate touch and may not know how to interpret therapeutic touch from the health care worker. Touch is not responded to similarly by all individuals.

How can a nurse use active listening to support a patient who demonstrates poor problem solving skills? Select all that apply. 1 Providing the patient with an opportunity to practice problem solving skills. 2 Giving the patient appropriate feedback to attempts at problem solving. 3 Affording the patient a chance to "think out loud" while articulating problems. 4 Making suggestions regarding how the patient possibly can solve problems. 5 Presenting undivided attention enhances a patient's self-esteem regarding problem-solving abilities.

1,2,3,5 Active listening helps strengthen the patient's ability to solve problems. By giving the patient undivided attention, the nurse communicates that the patient is not alone. This kind of intervention enhances self-esteem and encourages the patient to direct energy toward finding ways to deal with problems. Serving as a sounding board, the nurse listens as the patient tests thoughts by voicing them aloud. This form of interpersonal interaction often enables the patient to clarify thinking, link ideas, and tentatively decide what should be done and how best to do it. These skills are not encouraged by the nurse who provides solutions.

During a conversation with a patient, which behavior demonstrated by the nurse is a characteristic of effective body language? Select all that apply. 1 Maintain eye contact with the patient to confirm interest in the conversation. 2 While maintaining personal space boundaries, lean in slightly to show attentiveness. 3 Use frequent hand gestures to suggest agreement with the patient. 4 Mimic the patient's facial expressions, especially those of happiness and sadness. 5 Sit with arms crossed to convey a sense of authority.

1,2,4 A person who leans in slightly toward the speaker, maintains a relaxed and attentive posture, makes appropriate eye contact, makes hand gestures that are unobtrusive and smooth while minimizing the number of other movements, and who matches facial expressions to personal feelings or to the patient's feelings can be perceived as open to and respectful of the communication. A person who slumps in a chair, rolls the eyes, and sits with arms crossed in front of the chest can be perceived as resistant and unreceptive to what another wants to communicate.

Which statement demonstrates that the nurse understands the guidelines for effectively interviewing a patient who is grieving the loss of a spouse? Select all that apply. 1 "I sense you are stressed and so this interview will be as brief as possible." 2 "It is important that you are able to share with me how losing your spouse has made you feel." 3 "I believe it's important that you talk to your children about what they can do to help you." 4 "Your body posturing makes me think that you are especially anxious about something." 5 "I have worked with many grieving people and I really think I can help you."

1,2,4 Classic guidelines for conducting the initial interview include speaking briefly, when you do not know what to say, say nothing, when in doubt, focus on feelings, avoid giving advice, avoid relying on questions, pay attention to nonverbal cues, and keep the focus on the patient. The incorrect options both offer advice.

A nurse is conducting a clinical interview of a patient who is a victim of a road traffic accident. Which appropriate therapeutic techniques does the nurse implement? Select all that apply. 1 Maintain silence 2 Make observations 3 Make value judgments 4 Provide false reassurances 5 Change the topic 6 Give broad openings

1,2,6 Maintaining silence, making observations, and giving broad openings are effective therapeutic techniques. Maintaining silence gives the patient time to recollect and think. Making observations and calling attention to the patient's behavior helps to cut silence and start a conversation with a withdrawing patient. Giving broad openings promotes long conversations and makes the patient respond. Making value judgments prevents problem solving, and the patient may get angry or dissatisfied. Falsely reassuring will make the patient feel unimportant. Changing the topic will make the patient feel isolated and hopeless.

What sociological factors have contributed to the effectiveness of telehealth technology in addressing the mental health care needs of rural populations? Select all that apply. 1 The lack of mental health providers in rural areas. 2 The generalized mistrust of traditional health care facilities. 3 The fear of being associated with the stigma of being mentally ill. 4 Rural places have little public transportation. 5 The traditionally low income of the rural population.

1,3,4 Most mental health issues are not addressed because of the fear of stigma, the scarcity of health care providers in remote areas, or problems with transportation. The technology immunizes the impact of these issues by eliminating the need for extensive travel, improves access to health care providers, and maximizes confidentiality. While mistrust and low income may exist, they are not factors that the new technology impacts.

A nurse is interviewing a patient who has attempted suicide. What question does the nurse ask to start the interview? 1 "Are you happy that you survived?" 2 "What made you attempt suicide?" 3 "Did you really want to commit suicide?" 4 "What if you hadn't survived?"

2 A nurse always starts an interview by asking open-ended questions of the patient, like what made the patient attempt suicide. This helps to know the patient and establishes a rapport. Whether the patient is happy about his or her survival or whether the patient really wanted to attempt suicide are closed-ended questions. These questions limit the conversation and stop the patient from sharing information. What if the patient hadn't survived is a projective question that may make the patient feel guilty and hinder the conversation.

A nurse should perceive an intense, highly emotional communication style as culturally appropriate for a patient who is 1 African American 2 Hispanic American 3 Asian American 4 British America

2 Highly emotional verbal communication accompanied by dramatic body language when describing emotional problems is a style associated with persons of Hispanic culture. French and Italian Americans also demonstrate animated facial expressions and expressive hand gestures during communication.

The student nurses were asked to arrange seats to conduct clinical interviews with HIV patients. What would be the appropriate seating arrangement for the interview? 1 Chairs must be placed at different levels. 2 Chairs must be arranged at 90-120 degrees. 3 The patient's chair must be placed between the nurse and the doctor. 4 The patient's chair must be kept in one corner of the room

2 In all clinical interview settings, the seating arrangement is done in such a way that proper eye contact can be maintained and avoided when required. Therefore, chairs must be placed at 90-120-degree angles. Chairs should be placed at the same level. If the patient is placed between the nurse and the doctor, the patient may feel trapped. Effective communication is not possible if the patient sits in a chair in one corner of the room.

A nurse is assigned to conduct a clinical interview of a patient with Alzheimer's disease. The nurse starts the interview by asking the patient, "What would you like to discuss?" Which therapeutic technique did the nurse follow? 1 Encouraging description of perception 2 Giving broad openings 3 Exploring the patient's thoughts 4 Suggesting collaboration

2 The nurse asked a question that made the patient articulate his or her thoughts better. The question indicated that the patient should start the conversation. Therefore, the nurse used the therapeutic technique of broad openings. Description of perception helps the nurse to understand the patient's perception. Exploring is aimed at knowing the ideas and experiences of the patient. Collaboration deals with communication related to working with the patient on the patient's problems.

A nurse is performing an assessment of a Hispanic patient who was physically abused by an intimate partner. The patient becomes distressed while reporting the abuse to the nurse. Which nonverbal therapeutic communication technique can the nurse implement to console and make the patient feel comfortable? Select all that apply. 1 The nurse stands very close to the patient. 2 The nurse avoids making eye contact. 3 The nurse holds the patient's hand. 4 The nurse avoids patting the patient's shoulder. 5 The nurse maintains fixed facial expressions.

2 The nurse avoids making eye contact. 3 The nurse holds the patient's hand. While caring for a Hispanic patient the nurse should avoid making prominent eye contact because it could make the patient feel uncomfortable. When a patient is distressed, the nurse should hold the patient's hand to give assurance. The nurse should not stand very close to the patient because it may be perceived as a threat. The nurse should pat the patient's shoulder to indicate support. The nurse should not maintain fixed facial expressions while interacting with any patient because it indicates boredom. This would make the patient feel that the nurse is not concerned.

A nurse is interviewing a patient. What does the nurse keep in mind when practicing Sommers-Flanagan active listening? Select all that apply. 1 Ask questions to obtain a detailed history of the patient. 2 Be alert while listening. 3 Breathe slowly while listening. 4 Repeat the patient's words frequently. 5 Close eyes while listening.

2,3,5 Active listening involves understanding the patient's problems clearly without any distraction. This encourages the patient to talk further. By following relaxation techniques like being alert, breathing slowly, and closing eyes, the nurse remains focused without getting distracted by personal worries about how to proceed with the interview. Asking questions can annoy the patient and hinder the nurse-patient communication. Repeating the patient's words frequently may be interpreted as lack of interest by the nurse. It is not an effective means of therapeutic communication.

Which statement made by a mental health nurse demonstrates the need for further education regarding active listening as a therapeutic communication technique? 1 "When I use therapeutic silence, I'm giving the patient time to think and reflect." 2 "Sharing perceptions doesn't mean I tell the patient how my experiences are similar to his or hers." 3 "I generally find it helpful to ask the patient why he or she blames others for the mistakes he or she has made." 4 "It's not therapeutic to give the patient suggestions as to what he or she needs to do to fix his or her problems."

3 Asking why the patient is behaving in a particular manner often is viewed as judgmental by the patient. Presenting such an attitude would be a barrier to communication and thus nontherapeutic. Stating, "When I use therapeutic silence, I'm giving the patient time to think and reflect" describes an effective use of silence. Sharing perceptions is used to clarify an understanding of what the patient is thinking or feeling. Suggestions are therapeutic only when given as possible alternatives for the patient to consider, not when given as advice.

When determining the appropriateness of touching a psychiatric patient, the nurse should 1 Follow his or her instincts concerning touching individual patients 2 Touch the elderly but avoid touching the young 3 Check the facility's policy on the acceptability of touch 4 Perceive touch as a gesture of warmth and friendship that fosters a relationship

3 Students are urged to check the policy manual of their facilities, because some facilities have a no-touch policy, particularly with adolescents and children who may have experienced inappropriate touch and would not know how to interpret the touch of the health care worker.

A Hispanic patient avoids eye contact when interacting with the nurse. What does the nurse infer from the patient's behavior? 1 The patient is depressed. 2 The patient is confident and enthusiastic. 3 The patient has respect for the nurse. 4 The patient is trying to hide emotions

3 The nurse should consider the cultural norms of the patient while caring for and interacting with him. It helps the nurse to maintain effective therapeutic relations and to interpret the feelings of the patient. Hispanics may avoid maintaining eye contact with nurses and primary health care providers because of respect. The patient is not depressed and is not trying to hide emotions; the patient avoids maintaining eye contact because of his culture. Avoiding eye contact does not indicate that the patient is confident and enthusiastic.

A patient is very upset about her newborn being diagnosed with erythroblastosis fetalis. What is an appropriate response by the nurse? 1 "Things get worse before they get better." 2 "Why didn't you take the Rh immunoglobulins?" 3 "You must be feeling very upset." 4 "Try to get out of the situation as soon as possible."

3 When the nurse says that the patient must be feeling very upset, it reflects the feelings of the patient, which is the most appropriate nursing response. The patient gets an impression of being understood, which encourages the patient to express feelings and ideas. When a nurse responds by saying that things get worse before they get better, it gives an impression to the patient that the nurse is unable to understand the patient's feelings and the patient may feel degraded. Asking the patient the reason for not taking Rh immunoglobulins makes the patient feel judged. Giving premature advice, such as to get out of the situation as soon as possible, indicates that the nurse is unable to understand the patient's feelings and is giving an opinion.

A nurse is caring for a Hispanic patient with diabetic nephropathy. Which nonverbal communication can the nurse have with the patient? Select all that apply. 1 Have prominent eye contact with the patient. 2 Avoid holding the patient's hand. 3 Avoid eye contact with the patient. 4 Pat the patient's shoulder. 5 Avoid intensely emotional gestures with the patient.

3,4 Communication patterns differ according to culture and tradition. People from the Hispanic community avoid direct contact with higher authorities. They consider it disrespectful to have direct eye contact. In Hispanic culture, patting the shoulder and holding hands makes them feel supportive and helps in having good communication. Hispanic people are expected to be intensely emotional during communication.

What should be the distance between the nurse and the patient while conducting the initial clinical interview of the patient? 1 0 to 18 inches 2 12 to 24 feet 3 18 to 40 inches 4 4 to 12 feet

4 It is important to maintain appropriate personal space while interacting with the patient. Patients belonging to different cultural groups vary in their perception. So, the nurse should maintain an appropriate distance to reduce the patient's anxiety. During the initial clinical interview, the nurse and the patient are strangers to each other; therefore, 4 to 12 feet is an appropriate distance to maintain. A distance of 4 to 12 feet is the social distance that is maintained between strangers and at formal social gatherings. A distance of 0 to 18 inches is maintained with those who are close and trusted. The nurse can maintain this shorter distance with patients once the therapeutic relationship has been established. A distance of 12 to 24 feet (more than 12 feet) should be maintained during public speaking. A distance of 18 to 40 inches is maintained between friends and colleagues.

Which communication techniques should the nurse use with a patient who has been identified as havingDifficulty expressing thoughts and feelings? 1 Using emotionally charged words and gestures 2 Offering opinions and avoiding periods of silence 3 Asking closed-ended questions requiring "yes" or "no" answers 4 Asking open-ended questions and seeking clarification

4 Open-ended questions give the patient the widest possible latitude in answering. Also, the patient can take the lead in the interview. Seeking clarification helps the patient clarify his or her own thoughts and promotes mutual understanding.

A nurse is caring for a patient with schizophrenia. The patient reports hearing threatening voices. The nurse asks the patient, "What are these voices saying to you?" Which therapeutic communication technique did the nurse use while interacting with the patient? 1 Using closed-ended questions 2 Offering general leads 3 Encouraging comparison 4 Using description of perception

4 The nurse is using the therapeutic technique of description of perceptions. It helps the nurse to understand the patient's perceptions. It also helps the nurse to know the feelings of the patient and to accordingly advise him or her to act appropriately. A closed-ended question does not enable the nurse to know the patient's perceptions and feelings. Offering leads helps the patient to continue the interaction with the nurse. Encouraging comparison is a therapeutic technique in which the nurse encourages the patient to develop his or her decision-making ability.

A patient on the psychiatric unit is sitting with his or her arms crossed over the chest and his or her left leg is moving up and down rapidly. The patient has an angry expression on his or her face. When approached, the patient states harshly, "I'm fine! Everything's great." Which response would be therapeutic? 1 "Okay, but we are all here to help you, so come get one of the staff if you need to talk." 2 "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going." 3 "I don't believe you. You are not being truthful with me." 4 "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?"

4 The statement "It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?" uses the therapeutic technique of clarifying; it addresses the difference between the patient's verbal and nonverbal communication and encourages sharing of feelings. "Okay, but we are all here to help you, so come get one of the staff if you need to talk," "I'm glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going," and "I don't believe you. You are not being truthful with me" do not address the patient's obvious distress or are confrontational and judgmental.

Of the following environments, which would be most conducive to a therapeutic session? The nurses' station A table in the coffee shop A quiet section of the day room The utility room

A quiet section of the day room Of the options provided, a quiet corner of the day room offers the safest, quietest, most private environment for a therapeutic encounter.

With which client should the nurse make the assessment that not using touch would probably be in the client's best interests? A recent immigrant from Russia A deeply depressed client A Chinese American client A tearful client reporting pain

Chinese Americans may not like to be touched by strangers.

When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" Focusing Restating Reflection Clarification

Clarification verifies the nurse's interpretation of the client's message.

During a therapeutic encounter, the nurse makes an effort to ensure the use of two congruent levels of communication. What is the rationale for this? The mental image of a word may not be the same for both nurse and client. One statement may simultaneously convey conflicting messages. Many of the client's remarks are no more than social phrases. Content of messages may be contradicted by process.

Content of messages may be contradicted by process. Verbal messages may be contradicted by the nonverbal message that is conveyed. The nonverbal message is usually more consistent with the client's feelings than the verbal message.

A nurse should perceive an intense, highly emotional communication style as culturally appropriate for a client who is African American. Hispanic American. Asian American. British American.

Hispanic American. Highly emotional verbal communication accompanied by dramatic body language when describing emotional problems is a style associated with persons of Hispanic culture. French and Italian Americans also demonstrate animated facial expressions and expressive hand gestures during communication.

During a therapeutic encounter the nurse remarks to a client, "I noticed anger in your voice when you spoke of your father. Tell me about that." What communication techniques is the nurse using? Giving information and encouraging evaluation Presenting reality and encouraging planning Clarifying and suggesting collaboration Reflecting and exploring

Reflecting and exploring Reflecting conveys the nurse's observations of the client when a sensitive issue is being discussed. Exploring seeks to examine a certain idea more fully.

What is the focus during clinical supervision? The nurse's behavior in the nurse-client relationship Analysis of the client's motivation for transferences Devising alternative strategies for client growth Assisting the client to develop increased independence

The nurse's behavior in the nurse-client relationship Clinical supervision helps the nurse look at his or her own behavior and determine more effective approaches to working with clients.

What therapeutic communication technique is the nurse using by asking a newly admitted patient, "Can you tell me what was happening to you that led to your being hospitalized here?" Using a minimal encourager Using an open-ended question Paraphrasing Reflecting

Using an open-ended question Open-ended questions require more than one-word answers.

During a clinical interview the client falls silent after disclosing that she was sexually abused as a child. The nurse should quickly break the silence and encourage the client to continue. reassure the client that the abuse was not her fault. reach out and gently touch the client's arm. allow the client to break the silence.

allow the client to break the silence. Silence is not a "bad" thing. It gives the speaker time to think through a point or collect his or her thoughts.

When determining the appropriateness of touching a psychiatric client, the nurse should follow his or her instincts concerning touching individual clients. touch the elderly but avoid touching the young. check the facility's policy on the acceptability of touch. perceive touch as a gesture of warmth and friendship that fosters a relationship.

check the facility's policy on the acceptability of touch. Students are urged to check the policy manual of their facilities, because some facilities have a no-touch policy, particularly with adolescents and children who may have experienced inappropriate touch and would not know how to interpret the touch of the health care worker.

After a client discusses her relationship with her father, the nurse asks, "Tell me if I'm correct that you feel dominated and controlled by him?" The nurse's purpose is to elicit more information. encourage evaluation. verbalize the implied. clarify message.

clarify message. Clarification helps the nurse understand and correctly interpret the client's message. It gives the client the opportunity to correct misconceptions.

When considering the interaction between verbal and nonverbal communication, what is the best word to complete this analogy: Verbal communication relates to content as nonverbal communication relates to touch. conflict. process. double messages.

process. The verbal message is sometimes referred to as the content of the message, and the nonverbal behavior is called the process of the message.

When the client sits about 5 feet away from the nurse during the assessment interview, the nurse interprets that the client views the nurse as a safe person to interact with. new friend. stranger. peer.

safe person to interact with Social distance (4-12 feet) is reserved for strangers or acquaintances. This is often the client's perception of staff during the initial phase of relationship-building.

The preferred seating arrangement for a nurse-client interview is with the nurse behind a desk and the client in a chair in front of the desk. the nurse and client sitting at a 90-degree angle to each other. the client sitting in a chair and the nurse standing a few feet away. the nurse and client sitting facing each other.

the client sitting in a chair and the nurse standing a few feet away. This arrangement allows the nurse to observe the client but places no barriers between the principals. The two are at the same height, so neither is in an inferior position. Face-to-face seating is a more confrontational arrangement and therefore more anxiety producing.