Chapter 27

19. Which term describes the final stage in the normal process of anxiety? a. Panic b. Crisis c.Disorganization d. Coping

ANS: D The individual moves from experiencing the symptoms of anxiety to the use of coping behaviors to alleviate these symptoms. Panic is a level of anxiety. Crisis involves disorganization, which is not always the end product of anxiety. Disorganization is not always experienced as the product of anxiety.

13. After a mass transit disaster many injured patients are expected at the emergency room. The nurse prepares to plan interventions for which likely mental health assessment findings? a. Dissociative symptoms, numbing, detachment, and derealization b. Auditory hallucinations and other perceptual distortions including paranoia c. Somatic neurologic disorders and amnesia d. Exaggerated mood including both depression and manic-related elation

ANS: A Acute stress reactions are marked by dissociative symptoms such as numbing of emotional responsiveness, feelings of detachment, and decreased awareness of surroundings. The other options list behaviors that are atypical of acute stress reactions.

15. The nurse would expect which comment from a patient diagnosed with depersonalization disorder? a. "I feel like I'm outside my body, watching what's happening." b. "I feel as though someone is reading thoughts in my mind." c. "I know I have cancer, but the doctors can't find it." d. "When I woke up, my legs were paralyzed."

ANS: A In depersonalization, individuals feel detached from parts of their body or their mental processes. The distracters reflect somatization disorder, conversion disorder, and schizophrenia.

8. A patient is hospitalized with somatic blindness. The patient is unconcerned about the blindness and says, "I'm sure things will turn out all right." Which term best describes this reaction? a. La belle indifference b. Trance c. Dissociation d. Fugue

ANS: A La belle indifference refers to an attitude of unconcern or indifference about a symptom when the symptom is unconsciously used to lower anxiety. Dissociative disorders are characterized by a disruption in consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative fugue involves a lack of memory for a move or change of identify. A trance is a half-conscious state characterized by an absence of response to external stimuli.

17. What should the priority focus of milieu management be for a client diagnosed with dissociative identity disorder (DID)? a. Ensuring client safety b. Stimulating memory return c. Attending insight-oriented group therapy d. Gathering data about family relationships

ANS: A Patients with DID have a host personality and one or more alternates. It is not unusual for one of the alternate personalities to be depressed and wish to commit suicide or for a personality to wish to harm the others. Safety is the priority concern in care. None of the other options are directly associated with the primary issues of DID

11. What is the nurse's initial action when working with a patient with diagnosed with posttraumatic stress disorder (PTSD)? a. Assure the patient that the nurse can be trusted. b. Work with the patient to find a way to reduce stress. c. Encourage verbalization rather than physical acts to address anger. d. Support the patient's ability to evaluate past behaviors as either effective or noneffective.

ANS: A Patients with PTSD are often withdrawn and feel suspicious, detached, or estranged from others. Developing a trusting relationship might be difficult for them; however, the development of trust is fundamental to the therapeutic nurse-patient relationship. The other interventions will not be possible until a trusting relationship exists.

1. A patient diagnosed with posttraumatic stress disorder (PTSD) has frequent flashbacks and persistent hyperarousal symptoms. Which nursing interventions should be planned to effectively need the patient's needs? (Select all that apply.) a. Offer empathy and support. b. Encourage relaxation activities. c. Encourage verbalization of anger. d. Set limits when the patient begins to tell of the story of the traumatic incident. e. Help the patient associate current feelings and behaviors with trauma experience.

ANS: A, B, C, E These measures are designed to help reduce PTSD symptoms. Anger should be expressed and accepted. Patients with PTSD should learn that their feelings are commonly experienced by others with the same disorder. Recounting the traumatic event helps patients integrate the feelings of distress, so limiting such behavior is not therapeutic.

24. A nurse is assigned to care for a patient diagnosed with moderate (+2) anxiety. Which assessment findings are most likely? a. Distorted perceptions, disorientation, and defensiveness b. Poor concentration, narrow perceptions, and irritability c. Irrational reasoning and loss of contact with reality d. Alertness, attentiveness, and accurate perceptions

ANS: B In moderate anxiety states, the body is preparing for protective action. Cognitive symptoms include difficulty concentrating, distractibility, narrowed perceptions, short attention span, tangentiality or circumstantiality, and decreased problem-solving ability. Alertness is associated with mild anxiety. Distorted perceptions are associated with severe anxiety. Irrational reasoning is associated with panic.

21. If a patient's threshold set point for anxiety is lowered, the nurse can expect subsequent stressors to: a. have a lesser effect. b. easily reactivate the anxiety response. c. produce marked personality disorganization. d. be easily managed using familiar coping strategies.

ANS: B Lowering the threshold set point for anxiety will result in the patient becoming anxious more easily. Thus, lesser effect and ease of handling are incorrect options. Marked personality disorganization would not necessarily occur.

1. Which statement demonstrates a nurse's understanding of the first intervention when caring for a patient experiencing severe anxiety over an impending divorce? a. "Let me you solve the biggest problem the divorce will cause you." b. "I want you know I'll be here to keep you safe." c. "Please tell me what today's date is." d. "You can go into your room and close the door when you need privacy."

ANS: B Patients with anxiety disorders experience discomfort from the anxiety. The patient must feel safe, acknowledged, and cared for before problem-solving can begin. The nurse's first priority is to provide support and understanding. Allowing the patient to remain alone fosters social withdrawal and may allow anxiety to increase. Patients with anxiety seldom lose contact with reality.

20. The effects of stress can be seen by measurement of clinical changes of the body. This statement is a tenet of which theorist? a. Freud b. Selye c. Peplau d. Sullivan

ANS: B Selye found that the effects of stress can be seen by objective measurement of structural and clinical changes in the body. Roy nursing theory uses this foundation. None of the other options deal with stress.

2. A patient diagnosed with obsessive-compulsive disorder (OCD) experiences improvement after beginning treatment with a selective serotonin reuptake inhibitor (SSRI). This phenomenon supports the theory that OCD is associated with what neurotransmitter issue? a. Norepinephrine deficiency b. Serotonin dysregulation c. Dopamine excess d. GABA deficiency

ANS: B Serotonin dysregulation is hypothesized to play a part in OCD. Relief associated with SSRIs supports this hypothesis. The other theories are nonrelated.

18. What is the most important assessment question to ask a patient suspected of having a dissociative disorder? a. "Do any members of your family have problems with drugs or alcohol?" b. "Do you ever find yourself in places with no idea how you got there?" c. "How would you describe your current level of anxiety?" d. "How do you think we can be of help to you?"

ANS: B The correct response would provide information relevant to dissociative amnesia, dissociative fugue, or dissociative identity disorder, making it a good assessment question. The other questions are of no particular relevance to a dissociative disorder assessment.

14. Which statement by a patient diagnosed with somatic symptom disorder indicates that goals for treatment are being achieved? a. "I need to be very careful about what I eat." b. "I can focus on things other than my symptoms." c. "I understand that my doctor is not an expert in everything." d. "I try to figure out my diagnosis by reading articles on the Internet."

ANS: B This statement suggests that the patient's preoccupation with physical symptoms has decreased. The other options suggest ongoing concern with his or her physical state.

25. The nurse is assigned to care for a patient with moderate anxiety (+2). Which intervention will best manage the patient's signs and symptoms? a. Appropriate use of time-out b. Initiating problem-solving techniques c. Planning care to include firm guidance and control d. Assessing the need for a parenteral antianxiety drug

ANS: B Using problem-solving is an appropriate goal for a patient experiencing moderate anxiety, because these patients are capable of problem-solving with assistance. Use of time-out, providing firm guidance and control, and giving parenteral medication are interventions more often used for severe and panic-level anxiety.

22. An anxious patient has distorted perceptions and ineffective reasoning. On an anxiety rating scale, the nurse would expect to record the patient's level of anxiety at what level? a. Mild, +1 b. Moderate, +2 c. Severe, +3 d. Panic, +4

ANS: C Cognitive symptoms of severe anxiety include distorted perceptions, difficulty focusing, and ineffective reasoning. Other symptom constellations relate to the other levels.

9. Which principle best applies to care of a patient diagnosed with conversion disorder? a. Structure care to provide time for rituals. b. Facilitate progressive review of the trauma. c. Give attention to the patient, not the symptom. d. Permit dependence while the symptoms are acute.

ANS: C Often, patients with conversion disorder think that their symptom makes them interesting and that they are not interesting as persons. The nurse should matter-of-factly accept the symptom without focusing on it and direct attention to the person as an individual. Two distracters refer to care of a patient with OCD and care of a patient with PTSD.

5. When working with a patient diagnosed with dissociative amnesia, the nurse should begin the care by implementing which intervention? a. Setting mutual goals for behavioral changes b. Instituting measures to prevent identity diffusion c. Identifying and supporting the patient's strengths d. Helping the patient develop a realistic self-concept

ANS: C Strengths serve as the foundation for later therapeutic work to promote more adaptive coping, so identifying and supporting strengths is a fundamental initial intervention. The other options are useful but are not achievable until the patient's coping mechanisms (strengths and weaknesses) have been identified.

16. Which assessment data supports a patient's diagnosis of dissociative fugue? a. Preoccupation about having a serious disease b. Feeling of detachment from one's body c. Believing that part of the body is ugly or disproportionate d. Having no memory of assuming a new identity

ANS: D Dissociative fugue involves unplanned travel away from one's usual home and either confusion about identity or assumption of a new identity. The person does not seem to be wandering but behaves purposefully. The other options relate to body dysmorphic disorder, depersonalization disorder, and hypochondriasis.

10. A patient diagnosed with panic attacks frequently awakens from sleep and is diaphoretic and hyperventilating. What instruction should the nurse provide the patient to help manage this situation in the future? a. Immediately use one of the various relaxation techniques they've learned. b. Immediately use the call bell to alert staff of the panic attack. c. Get out of bed immediately and watch television as a distraction. d. Immediately breathe into a paper bag kept in the nightstand.

ANS: D Hyperventilation should be addressed immediately by having the patient breathe using a paper bag. Bringing breathing under control will help diminish the other symptoms. The calm presence of the nurse is vital to symptom reduction. The other interventions would not be effective in relieving the hyperventilation.

7. A driver was trapped in a car for several hours after an earthquake caused a bridge to collapse. A year later this person still has nightmares and re-experiences feelings of fear associated with being trapped in the car. The assessment findings are consistent with symptoms of which mental health diagnosis? a. Agoraphobia b. Panic attacks c. Generalized anxiety disorder (GAD) d. Posttraumatic stress disorder (PTSD)

ANS: D PTSD follows exposure to a traumatic event. Symptoms include those described in the scenario, as well as persistent symptoms of arousal and avoidance of stimuli associated with the traumatic event. GAD is an anxiety disorder that lacks a focus or trigger. Agoraphobia is characterized by marked fear or anxiety triggered by real or anticipated exposure to certain situations. A panic attack is an abrupt surge of intense fear or discomfort that peaks within 10 minutes.

23. A patient is demonstrating severe (+3) anxiety. Nursing interventions should center around which patient need? a. Encouraging ventilation and refocusing attention b. Discussing possible sources of anxiety c. Taking control to guide the patient d. Decreasing stimuli and pressure

ANS: D Severe anxiety requires intervention to relieve the heightened tension and discomfort that the patient is experiencing. Perceptions are often distorted, focusing is difficult, and problem-solving is impossible, even with help. Environmental simplification and kind, firm directions are approaches to decreasing stimuli and pressure. The other options will not be as effective.

4. A patient's family member died in the 9/11 World Trade Center explosion. The patient says, "I can't go into tall buildings because I get sweaty, my heart races, and I can't breathe. I get terrifying feelings the building will explode." Which response demonstrates the nurse's understanding of this symptoms/signs? a. "What rituals do you preform to control your anxiety?" b. "Have you ever been diagnosed with generalized anxiety disorder (GAD)?" c. "Your symptoms/signs suggest possible acute stress disorder (ASD)." d. "It appears you are experiencing a specific phobia associated with your family's tragedy."

ANS: D Specific phobias typically develop after a traumatic event or observing others going through a traumatic event. The extreme physical and emotional reactions are consistent with panic-level anxiety. Rituals are associated with obsessive-compulsive disorder (OCD). GAD lacks a general focus while an acute stress disorder would not be associated with an event so long ago.

3. A patient says, "I have the same continuous and intrusive thoughts that my house is contaminated with lethal bacteria. I spend hours cleaning the walls, floors, and furniture." These symptoms are most consistent with which diagnosis? a. Social phobia b. Panic disorder c. Somatoform disorder d. Obsessive compulsive disorder (OCD)

ANS: D The patient's persistent intrusive thoughts are obsessions, and the need to continually clean is a compulsion. Hence, the patient's disorder can be identified as OCD. The symptoms are not consistent with a fear of interacting with others, extreme fear, or physical symptoms that have no physiological basis.

6. A patient diagnosed with obsessive-compulsive disorder (OCD) paces up and down the corridor counting every floor tile. How should the nurse address the patient's behavior? a. Offer to play cards with the patient in the dayroom as a distraction. b. Encourage the patient to focus by asking, "Why are you pacing and counting?" c. Interrupt the behavior by taking the patient's arm and escort the patient to a quiet area. d. Permit the patient to pace and count while monitoring for safety.

ANS: D The performance of the pacing-counting ritual is decreasing the patient's anxiety. Stopping will increase anxiety. Rituals should be restricted only when they physically endanger the patient. The other options will not promote anxiety reduction for this patient.

12. Which statement made by an individual diagnosed with PTSD best indicates that treatment was effective? a. "I'm drinking less now that I've faced my problems." b. "I feel like the accident happened to someone else." c. "I sleep for 3 to 4 hours a night without nightmares." d. "My artwork distracts me and eases my anxiety."

ANS: D Treatment has been successful when an individual can use coping mechanisms to move forward and find meaning in the traumatic event. Continued use of drugs and alcohol is maladaptive. Continued sleep disturbances and insomnia as well as dissociation or depersonalization do not indicate that treatment was effective.