MH Mod 2

A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply.) A. Age older than 65 years B. Anxiety disorder C. Female gender D. Coronary artery disease E. Obesity

B, C

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C

Conversion disorder i

i: • Treat the symptoms as real • Use problem solving approach • Help to meet needs in more direct ways

A client with phobias about elevators and large crowds comes to the clinic for help because of feelings of depression related to these fears. What is an appropriate short-term goal for this client?

1 Riding an elevator without anxiety when accompanied by the nurse Correct2 Describing the thoughts and feelings experienced in terrifying situations 3 Experiencing an elevation of mood and relief from feelings of depression 4 Identifying the early childhood conflicts that resulted in the development of these fears Describing the thoughts and feelings experienced in terrifying situations is a realistic essential first step. The problem and related feelings must be thoroughly explored before solutions can be developed. Riding an elevator without anxiety when accompanied by the nurse is a long-term goal. Experiencing an elevation of mood and relief from feelings of depression is a long-term goal. Identifying the early childhood conflicts leading to the development of the fears is an inappropriate goal; a direct connection to life events is often difficult to find.

PTSD time frame

1 month

PDD diagnosis

2 years

GAD diagnosis

DSM 3 out of 6 symptoms

MDD diagnosis

DSM 5 symptoms 2 weeks

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse?

Developing a wide variety of coping strategies increases the individual's ability to cope with stress; different defenses can be used in various situations. The client has already identified the problem. Improved time-management skills may or may not be helpful. People should not ignore situations that affect them.

You are teaching a patient how to utilize deep breathing as a technique for relaxation. Place the steps in order:

1. Inhale through your nose 2. Be sure you breath is deep enough to expand your abdomen 3. Hold for 3 seconds 4. Slowly exhale through your mouth 5. Remind yourself to relax 6. Repeat for 2-5 minutes

A nurse is teaching a patient about stress-reduction techniques. Which patient statement indicates understanding of the teaching? A. Physical exercise causes my body to release endorphins so that I feel less stress and anxiety. B. Cognitive reframing allows me to prioritize the stressor that I ahve in my life so that I have less anxiety C. Progressive relaxation uses a mechanical device to help me gain control over my pulse rate. D. Biofeedback will help me change my irrational thoughts to something positive.

A

A nurse is caring for a client who has post-traumatic stress disorder (PTSD) following several months in a military combat situation. • List three subjective and three objective manifestations of PTSD. • List three nursing actions for a client who has PTSD. • Describe two therapeutic techniques used to treat a client who has PTSD.

Subjective: - Dreams/flashbacks of the traumatic event - Insomnia - Verbalizes guilt, self-blame Objective: - Hyperactive startle reflexes - Manifestations of anxiety: tachycardia, hyperventilation, inability to focus in order to complete a simple task Three Nursing Actions: - Monitor for suicidal ideation + take precautions - Provide a safe, routine, environment for the client - Teach strategies to decrease anxiety such asbreathing techniques, music therapy - Encourage the client to share feelings - Use therapeutic communication techniques to assist a client who has cognitive distortions Therapeutic techniques: - EMDR - CBT - group and family therapy

Anxiety due to a medical condition

•Anxiety symptoms directly related to a person's medical condition.

Which is an effect of stress on the body? A. Hyperglycemia B. Hypersomnia C. Bradypnea D. Euphoria

A

The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. Which statement leads the nurse to conclude that the client is experiencing secondary gains from her behavior?

"I'm as big as a house." 2 "I get straight A's in school." Correct3 "My mother keeps trying to get me to eat." 4 "My hair is beginning to fall out in clumps." The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, perfectionism, and achievement and may obtain high grades in school, good grades are not a secondary gain related to the eating behaviors associated with anorexia nervosa. Hair falling out in clumps is a result of starvation, not a secondary gain.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is what?

1 A physiologic response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention Correct4 An unconscious means of reducing stress When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level and is not intentional.

Shortly after the death of her husband after a long illness, a woman visits the mental health clinic complaining of malaise, lethargy, and insomnia. The nurse, knowing that it is most important to help the wife cope with her husband's death, should attempt to determine which information?

1 Age of the wife 2 Timing of the husband's death 3 Socioeconomic status of the couple Correct4 Adequacy of the wife's support system Support is most important when coping with the crisis of death; the client must rely on the support system to cope with the loss. The client's age may play a role in coping, but it is not the most important factor. The timing may be important if the death is just one of multiple stresses, but it is not the most important factor in helping a client cope. Socioeconomic status may be important in long-term planning, but it is not the most important factor in the grieving process.

A school nurse is caring for a 12-year-old child with school phobia. What should the nurse anticipate will be included in the initial treatment plan?

1 Allowing a parent to stay with the child during school Correct2 Having the child present somewhere in the school building during the day 3 Encouraging the child to attend school at brief intervals throughout the day 4 Providing home schooling until the child feels less anxious about attending school When the child is present in the school, even in the library or the nurse's office, the child can be helped to improve coping and eventually decrease the phobia through desensitization. Secondary gains from missing school are eliminated with this approach. Allowing a parent to stay with the child during school will be disruptive to the child's class and will focus unnecessary attention on the child. Having the child go in and out during the day will be disruptive and will not help desensitize the child. Providing home schooling until the child feels less anxious about attending school will reinforce the school phobia and make returning to school more difficult.

A nurse interviewing a client being admitted for acute anxiety asks, "What brought you to the emergency department tonight?" Which response best demonstrates that the client's cognitive abilities have been affected by the anxiety?

1 "It's obvious why I came to the emergency department." Correct2 "The ambulance brought me to the emergency department." 3 "Why do you want to know why I came to the emergency department?" 4 "What do you mean by 'What brought you to the emergency department'?" Cognitive impairment is a common response to acute anxiety. Such impairment is often observed as an inability to appropriately interpret abstract questions. The response is generally very concrete, as seen in the client's response to the nurse's question, "The ambulance brought me to the emergency department." The statement "It's obvious why I came to the emergency department" demonstrates agitation rather than cognitive impairment. "Why do you want to know why I came to the emergency department?" is a response that demonstrates paranoia rather than cognitive impairment. The question "What do you mean by 'What brought you to the emergency department'?" demonstrates a fairly high degree of cognitive processing, because the client is asking for clarification.

A 20-year-old student comes to the college health clinic reporting increasing anxiety, loss of appetite, and an inability to concentrate. What is the most therapeutic response by the nurse?

1 "Who have you shared your feelings of anxiety with?" 2 "What have you identified as the cause of your anxiety?" Correct3 "It's been difficult for you. How long has this been going on?" 4 "Let's talk about your problems. Are you having difficulty adjusting?" Noting that the situation has been difficult for the client and asking how long it has lasted acknowledges feelings and attempts to collect more data. Asking whom the client has shared the situation with will not facilitate the collection of data about the extent of anxiety. Anxiety is most often a response to a vague, nonspecific threat; the client will not be able to explain what causes it. It is too early to try to identify the cause of the anxiety; crisis intervention with anxious clients requires a more structured approach than "Let's talk."

Phobia

•Illogical, intense fear of a specific object or social situation with extreme distress •May be agoraphobia, specific or social •Knows anxiety is irrational, yet attempts to avoid feared object or situation.

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." How should the nurse interpret the client's communication?

1 As a call for help to prevent the client from acting on suicidal thoughts 2 As a manipulative attempt to persuade the nurse to call the daughter Correct3 As a reflection of depression that is causing feelings of hopelessness 4 As a request for information about social support groups in the community This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented should not lead the nurse to conclude that the client is looking for help to prevent suicidal activities, is attempting to manipulate the nurse, or is looking for information about community social support groups.

A 15-year-old client is brought to the high school health office by two friends, who report, "We think our friend just took a handful of pills." The adolescent appears alert and subdued. The school nurse's initial response should be to do what?

1 Ask the friends where the adolescent got the pills. Correct2 Ask the adolescent whether she took any pills. 3 Call the rescue squad to stand by for an emergency. 4 Call the adolescent's parents to tell them to come immediately. Asking the client is the most direct approach to ascertaining whether pills were ingested; the client will usually respond to this type of direct question. Asking the friends where the adolescent got the pills does not provide useful information. Calling the rescue squad to stand by for an emergency is not the initial response; a determination must first be made regarding the number of pills taken. Calling the adolescent's parents to tell them to come immediately is appropriate later; it is not the priority now.

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the primary healthcare provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent?

1 Confrontation Correct2 Open communication 3 Health teaching about child-rearing 4 Validation of the child's physical status Maintaining open communication is important for any therapeutic nurse-client relationship. Confrontation will put the parent on the defensive and close off communication. Health teaching at this time is premature; the parent is not ready for this approach. Validation of the child's physical status focuses on the physical symptoms, which will reinforce the parent's behavior.

The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting?

1 Cry for help 2 Suicide attempt 3 Attention-seeking behavior Correct4 Way to manage overwhelming feelings Self-injurious behavior is used to soothe or override painful feelings. Recent studies do not link cutting to suicidal thinking. Cutting behavior is often hidden from others; it is not attention-seeking behavior.

What should a nurse include in the initial plan of care for a client with the long-standing obsessive-compulsive behavior of handwashing?

1 Determining the purpose of the ritualistic behavior 2 Limiting the time allowed for the ritualistic behavior 3 Suggesting a symptom-substitution technique to refocus the ritualistic behavior Correct4 Developing a routine schedule of activities to reduce the need for the ritualistic behavior Knowledge of a schedule allows the client to prepare for transitions; hurrying may increase anxiety and spur the need to perform the ritual. Routines will also ease anxiety and reduce the need for the ritual. Determining the purpose of the ritualistic behavior is one of the objectives to be accomplished later during the client's hospitalization, not in the initial phase. Some clients will never be able to identify the purpose of their rituals beyond the fact that they help ease anxiety. Limiting the time allowed for the ritualistic behavior is not an initial intervention, because it will increase anxiety. Suggesting a symptom-substitution technique to refocus the ritualistic behavior action is an appropriate intervention during the working phase of the nurse-client intervention, not the initial phase.

Which nursing intervention is indicated for a client with an anxiety disorder?

1 Encouraging suppression of anger by the client Correct2 Promoting verbalization of feelings by the client 3 Limiting involvement of the client's family during the acute phase 4 Explaining why the client should accept the psychological factors that are precipitating the anxiety Freedom to express feelings serves as a safety valve to reduce anxiety. Suppression of anger or hostility may add to the client's anxiety. Limiting involvement of the client's family during the acute phase may or may not be helpful; the client's family members may provide support. Explaining why the client should accept the psychological factors that are precipitating the anxiety is not therapeutic; accepting current situational stresses may not be possible.

The parents of an adolescent who is experiencing posttraumatic stress disorder have decided to care for their child at home. What is the priority intervention that the home health nurse must include in the plan of care?

1 Encouraging the parents to keep their child in the home environment 2 Helping the parents identify the things that cause the child to be fearful Correct3 Helping the parents understand that their child may avoid emotional attachments 4 Discussing with the parents their feelings of ambivalence about what their child is enduring The client will tend to avoid emotional attachment to significant others, because this is a common way to protect the self from the experience of potential future losses. The priority at this time is to have family members develop an understanding of what is happening to the client. Although it is important to keep the client safe and secure when in the home, the family should not restrict the client to the home environment. Although issues concerning the client's problems need to be resolved, this is not the priority. Although a discussion of the parents' feelings of ambivalence may be necessary, it is not the priority.

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis?

1 Making huge efforts to avoid "any kind of bug or spider" 2 Experiencing flashbacks to an event that involved a sexual attack Correct3 Spending hours each day worrying about something "bad happening" 4 Becoming suddenly tachycardic and diaphoretic for no apparent reason Using worrying as a coping mechanism is a behavior characteristic of GAD. Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of posttraumatic stress disorder (PTSD).

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. What defense mechanism does the nurse know is being utilized by this woman?

1 Projection 2 Regression Correct3 Repression 4 Displacement Repression occurs when an individual unconsciously excludes distressing emotions, thoughts, or experiences from her awareness. It is a mechanism to help her deal with the shock of stressful emotional experiences. A repressed memory is "forgotten" and cannot be deliberately brought to awareness. Projection occurs when an individual attributes his or her own unacceptable feelings and thoughts to others, allowing the individual to blame others for personal shortcomings. Regression occurs when an individual reverts to an earlier stage of development involving less mature behavior and responsibility as a way of coping with a stressful situation; it often results in more dependent behavior. Displacement occurs when an individual releases pent-up feelings on people perceived to be less dangerous than those who initially aroused the emotion. For example, after receiving a speeding ticket from the police a man yells at his wife when she asks him how his day went.

A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic?

1 Requiring the client to get out of bed Correct2 Staying with the client until the client calms down 3 Giving the client the as needed (PRN) antipsychotic that is prescribed 4 Leaving the client alone in bed for as long as the client wishes Staying with the client until the client calms down provides support and security without rejecting the client or placing value judgments on the behavior. Eventually limits will have to be set in giving care, but staying with the client and showing acceptance are immediate nursing actions. Although giving the client the PRN antipsychotic will calm the client, it does not address the problem. Leaving the client alone in bed for as long as the client wishes ignores the problem; isolation implies punishment.

What does the nurse recall is the major defense mechanism used by an individual with a phobic disorder?

1 Splitting 2 Regression Correct3 Avoidance 4 Conversion The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Splitting is the compartmentalization of opposite affective states and the inability to integrate the positive and negative aspects of others or self. Regression, the return to an earlier, more comfortable level of development, is not the defense mechanism used by someone with a phobia. Conversion, the transfer of a mental conflict to a physical symptom, is not the defense mechanism used by someone with a phobia.

A client is admitted with conversion disorder. What is the primary nursing intervention?

1 Talking about the physical problems Correct2 Exploring ways to verbalize feelings 3 Explaining how stress caused the physical symptoms 4 Focusing on the client's concerns regarding the symptoms The priority is getting the client to express feelings appropriately rather than through the use of physical symptoms. Clients with a conversion disorder are rarely concerned about the associated physical problem; this is known as la belle indifférence. An expression of feelings, not an intellectual understanding of the cause of the symptoms, is required. Avoidance of feelings resulted in the symptoms. Focusing on symptoms will encourage their use by the client.

A client with a dissociative identity disorder is to be discharged after a 2-week hospitalization. What does the nurse, evaluating the effectiveness of the short-term therapy, expect the client to verbalize?

1 The ability to deal openly with feelings 2 That many of the personalities can be ignored Correct3 The need for long-term outpatient psychotherapy 4 That the personalities serve no protective purpose A dissociative identity disorder is a complex, multifaceted problem that requires long-term therapy to achieve integration of the personalities. Each personality has the ability to deal openly with feelings, but the personalities need to be integrated. None of the personalities can be ignored, because their presence must be dealt with before integration can occur. The multiple personalities do serve a protective purpose. If they did not serve a protective purpose, they would be abandoned.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective?

1 Threats 2 Ideation Correct3 Gestures 4 Attempts A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

A client with the diagnosis of obsessive-compulsive disorder attends a day treatment program. The client feels that her hands are dirty and has a need to wash them 70 to 80 times a day, and, as a result, the client's hands are red and raw, with some bleeding. An immediate nursing intervention for this client is to get the client to do what?

1 Understand that the hands are not dirty. 2 Gain insight into the emotional problems. 3 Stop washing the hands so the skin will heal. Correct4 Limit the number of times handwashing occurs. Reducing but not eliminating the handwashing still permits the client to cope with feelings of anxiety while aiming to reduce skin damage. The anxiety is too great for the client to understand why handwashing is not necessary. Recognition must precede the development of insight; neither can be done until the level of anxiety is reduced. Telling the client that washing hands will not be permitted will not allow the client any outlet for coping with extreme anxiety, which is the priority need at this time. Also, the client must wash hands sometimes—for instance, after toileting.

A client is hospitalized with social anxiety disorder. The client has a history of exhibiting intense, irrational fear of being scrutinized by others. Which primary anxiolytic medications would be prescribed to the client? Select all that apply.

1 Sertraline 2 Paroxetine Correct3 Alprazolam 4 Venlafaxine Correct5 Clonazepam Manifestations of social anxiety disorder include stuttering, sweating, palpitations, dry throat, and muscle tension. Clients with this disorder exhibit intense, irrational fear of being scrutinized by others. Alprazolam and clonazepam are benzodiazepines that are well tolerated in clients, and the benefits are immediate. Sertraline and paroxetine are selective serotonin reuptake inhibitors that are also used in the treatment of social anxiety disorder, but they do not act quickly. Venlafaxine is used to treat posttraumatic stress disorder.

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

A

A nurse is participating in a community health fair focused on stress management. Which statement by a health fair participant indicates an understanding of how to manage stress? A. Aerobic exercise can reduce both chronic and acute stress B. Slower music has proven to promote relaxation C. Its important that every gets 9-10 hours of sleep D. Caffeine has negative effects on one's mood and physical body, and should be eliminated all together

A

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assessing the client's risk for self-harm B. Instilling hope for positive outcomes C. Encouraging the client to participate in group therapy sessions D. Encouraging the client to participate in treatment decisions

A

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Death of a child 2 months ago B. Recent weight loss of 30 lb C. Retirement 1 year ago D. History of migraine headaches

A

A nurse is teaching a patient about stress-reduction techniques. Which patient statement indicates understand of the teaching? A. Cognitive reframing will help me change my irrational thoughts to something positive. B. Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety. C. Biofeedback causes my body to release endorphins so that I feel less stress and anxiety. D. Progressive muscle relaxation uses a combination of muscle contraction/relaxation along with pleasant images, to produce feelings of relaxation

A

A patient on the mental health unit asks you to describe the stress-relieving technique of mediation. What is your best response? A. Mediation is focusing on an object and repeating a word or phrase while deep breathing. B. Mediation is a useful tool where people are taught to focus on pleasant images to replace negative or stressful feelings. C. Mediation is progressively tensing, then relaxing body muscles. D. Mediation is focusing on the present, and paying attention to what is going on around you. STOP is one technique

A

John tells the nurse that he suffers from test anxiety, and gets very stressed prior to and during exams. The nurse suggests that he takes short breaks during the exam to de-stress. Which relaxation technique would be most appropriate for the nurse to suggest? A. Deep breathing exercises B. Progressive relaxation C. Mental imagery D. Mindfulness

A

There is a strong correlation between lower mortality rates and one specific mediator of the stress response. Which mediator is supported by evidence? A. Social support B. Support groups C. Culture D. Spirituality/religion

A

Obsessive-compulsive disorder (OCD)

•Recurrent thoughts that are bothersome and disturbing (OBSESSIONS) with persistent ritualistic behavior (COMPULSIONS) •Person understands behavior is irrational, but maintains behavior to reduce anxiety •Anxiety will increase if interrupted •Depression and substance abuse may be complications of OCD

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive disorder E. Narcissistic personality

A, B, C, D

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Need for reassurance

A, D, E

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self‑image D. Recurring nightmares E. Diminished reflexes

A,C,D

A nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client, has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

B

A nurse recommends journaling to a patient who is experiencing stress. What is the best explanation for making daily entries into a personal journal? A. Expressing emotions to manage stress B. Identifying stress triggers C. Providing a distraction from the daily stress D. Expressing emotions to manage stress

B

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client explains that her body seems to be floating above the ground. B. The client has the idea that someone is trying to kill her and steal her money. C. The client states that the furniture in the room seems to be small and far away. D. The client cannot recall anything that happened during the past 2 weeks.

C

A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect? A. "I had to pretend I was injured in order to get disability benefits." B. "I know that my abdominal pain is caused by a malignant tumor." C. "I needed to make my son sick so that someone else would take care of him for a while." D. "I became deaf when I heard that my husband was having an affair with my best friend."

C

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed‑ended questions.

B, D

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a handwashing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is most important for the nurse to do when the client performs the ritual?

Correct1 Allow the client sufficient time to carry out the ritual. 2 Promote reality by showing that the ritual serves little purpose. 3 Try to ascertain the meaning of the ritual by discussing it with the client. 4 Interrupt the ritual to demonstrate that the ritual does not control what happens. Rituals provide a means for the individual to control anxiety. If not permitted to carry out the ritual, the client will probably experience unbearable anxiety. The client has exhibited verbally aggressive behavior in the past, and this behavior may escalate. Safety of the client and others becomes an issue. The client probably already understands that the ritual is useless but is unable to stop the activity. These clients have no idea of what the ritual means, only that they must continue the ritual. Interrupting the ritual will have the effect of increasing anxiety, possibly to a panic level.

A nurse is caring for a client who is depressed. When is the most important time for the nurse to be alert to the possibility of the client acting out suicidal thoughts?

Correct1 As the depression lifts 2 If the depression is severe 3 When the client has recovered from the depression 4 After the client understands the cause of the depression As the depression lifts, the client will have more psychic and physical energy to plan and implement a suicidal act. Also, some people who decide to commit suicide feel better because they believe that relief from their psychic pain will be coming soon as a result of their decision. The thoughts, actions, and decision-making ability necessary to plan and carry out suicide are decreased during severe depression. The client most likely will not be suicidal once recovery from the depression has occurred. After the client understands the cause of the depression, the likelihood of suicide is not increased. The client's energy level and the ability to make a decision to commit suicide are more important factors to consider.

A client is admitted to the psychiatric unit for severe depression with the potential for suicide. What is the most therapeutic nursing intervention when the client becomes more energized and communicative?

Correct1 Continuing to assess the client at regular intervals 2 Encouraging the client to participate in group activities 3 Giving the client more autonomy to decide about privileges 4 Starting to teach the client about medications in preparation for discharge Although the client appears to be improving, the possibility of suicide is still present, because the client's physical and psychic energy has increased. Although the client may now be able to participate more fully in groups, the safety issue of monitoring the client's mood and actions is the priority. It is too soon to increase privileges; the client's increase in physical and psychic energy may permit the client to act on suicidal thoughts. Teaching the client about medications in preparation for discharge should have been included in the initial plan of care.

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?

Correct1 Denial of this activity may precipitate a panic level of anxiety. 2 Anger turned inward on the self should be allowed to be expressed. 3 Successful performance of independent activities enhances self-esteem. 4 Ample time provides an opportunity to point out the inappropriate behavior. The repeated act protects the client against severe anxiety; interruption of the ritual will result in increased anxiety. The performance of a ritual is not anger turned inward on the self; the ritual reduces anxiety. Rituals are not activities that enhance self-esteem; they control anxiety. Pointing out that the behavior is inappropriate will further increase anxiety. The client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level.

When planning nursing care for a client with severe agoraphobia, what should the nurse do first?

Correct1 Determine the client's degree of impairment. 2 Support the client's self-esteem through verbal interactions. 3 Expose the client gradually to anxiety-provoking situations. 4 Teach the client biofeedback techniques for reducing anxiety. Assessment is the first step of the nursing process and must be done before care is planned. Nursing interventions follow assessment; a high level of anxiety interferes with verbal interaction. Exposing the client to anxiety-provoking situations or teaching biofeedback techniques may be done once the anxiety is reduced; assessment is the priority at this time.

When a client is expressing severe anxiety by sobbing in the fetal position on the bed, what is the nurse's priority?

Correct1 Ensuring a safe therapeutic milieu 2 Monitoring and documenting vital signs 3 Eliminating the cause of the client's anxiety 4 Ensuring that the client's physical needs are met Client safety is the nurse's first priority, and because the client has not experienced any physical injuries and is not at risk, attention should be directed toward psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital signs and will continue to have physiologic needs such as food and water; however, these issues do not take priority over a psychiatric crisis. The client will not be able to concentrate on therapy related to identifying the source of the anxiety until the crisis has been managed.

A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be?

Correct1 Staying physically close to the client 2 Gently asking what is bothering the client 3 Telling the client to try to relax by sitting quietly 4 Getting the client involved in a nonthreatening activity By staying physically close to the client during the time of severe anxiety, the nurse conveys the message that someone cares enough to be there during this frightening incident and that the client is a person worthy of care. The client is incapable of telling anyone what the problem is. Sitting still will increase the tension the client is experiencing. Involving the client in a nonthreatening activity is not an initial nursing intervention.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client?

Correct1 The illness is very real to the client and requires appropriate nursing care. 2 Although the client believes that there is an illness, there is no cause for concern. 3 There is no physiological basis for the illness; therefore only emotional care is needed. 4 Nursing intervention is needed even though the nurse understands that the client is not ill. Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions?

Correct1 Unconscious control of unacceptable feelings 2 Conscious use of this method to punish themselves 3 Acceptance of voices that tell her that doorknobs are unclean 4 Fulfillment of a need to punish others by carrying out the procedure In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others.

An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near-panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? Select all that apply.

Correct1 Identify the client's support systems. 2 Explore the client's psychotic thoughts 3 Reinforce the client's current self-image. Correct4 Encourage the client to talk about the situation. 5 Suggest that the client explore personal sexual attitudes. A client in crisis needs to rely on available sources of support for assistance; therefore it is vital for the nurse to identify the client's support system. Talking about the situation helps the individual put the crisis in perspective. Nothing in the history indicates that the client is having psychotic thoughts. Nor is there information to indicate that the client has issues with self-image. Suggesting that the client explore personal sexual attitudes will not help the client cope with the loss and may add to the client's anxiety.

A client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply.

Correct1 Obtaining vital signs Correct2 Assessing for suicidal thoughts Correct3 Instituting continuous monitoring Correct4 Initiating a therapeutic relationship Correct5 Inspecting the bandages for bleeding 6 Tell the client, "You have so much to live for. Your life isn't that bad." Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiologic stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid emotional recovery. Telling the client that their life isn't that bad and that they have much to live for does not promote therapeutic communication and is not appropriate.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques. B. Show the client how to change his behavior. C. Distract the client with a television show. D. Stay with the client and remain quiet.

D

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in his room. B. Monitor the client for self‑harm once per day. C. Allow the client unlimited time to discuss physical manifestations. D. Discuss alternative coping strategies with the client.

D

Panic Disorder diagnosis

DSM 4 symptoms 1 panic attack followed by 1+ month of at least one of the following: - persistent concern or worry about additional panic attacks - significant maladaptive change in behavior

Panic disorder

•Recurrent, unexpected panic attacks •1 month of persistent worry about having future attacks or consequences &/or significant maladaptive change in behavior related to attacks •Have four or more of the following symptoms: palpitations, sweating, tremors, shortness of breath, feeling of choking, chest pain, nausea/ abdominal distress, dizziness, paresthesia's, chills or hot flashes, derealization or depersonalization, fear of "going crazy", fear of dying. •Often seeks help in ER during the first attack.

Panic disorder treatments & interventions

Treatment: •Behavioral therapy combined with pharmacotherapy o SSRI, TCA, MAOI, and benzodiazepines •Positive reframing •Assertiveness therapy Nursing Interventions: •Remain calm during attack •Stay with patient •Reassurance •Reduce environmental stimuli

Phobia treatments & interventions

Treatment: •Behavioral therapy, ie flooding or systematic desensitization •Psychopharmacology o SSRIs o Anxiolytics o Beta blockers (social anxiety disorder) Inteventions: •Accepting but not supporting the phobia •Exploring person's perceptions of threats •Discussing feelings •Discussing strategies for change.

Obsessive-compulsive disorder (OCD) treatments & inteventions

Treatments: • Deep breathing & relaxation • Behavioral therapy such as flooding, thought-stopping, response prevention, • Psychopharmacology o SSRIs o Anafranil Inteventions: • Help person identify situations that lead to the behavior • Initially, allow time to complete rituals • Teaching after completion of ritual • Keep diary

A child who suffers from neglect will be at greater risk for the development of a mental illness as an adult. True or False

True

Acute stress disorder (ASD)

•Similar to PTSD, in that person has experienced a traumatic situation •Response is more dissociative in nature, a sense of unrealism.

Anxiety due to medical condition t&i

t: • Benzodiazepines, SSRIs • Education • Cognitive therapy i: • Reassurance • Information regarding medical condition and connection with anxiety • Encourages expression feelings

Post-Traumatic Stress Disorder (PTSD) t&i

t: • CBT • EMDR • Exposure • Psychopharmacology o SSRIs (first line) o Off label (prazosin, phenelzine, mirtazapine, mirtazapine) i: • Obtain accurate account of the traumatic event • Assess and acknowledge feelings • Non-threatening environment • Encourage discussing feelings • Psychoeducation • Assist to resume regular activities

Somatic Symptom Disorder t&i

t: • Long term management in medical setting • Treat symptoms conservatively • If depression is present, anti-depressants might help but avoid anti-anxiety agents • Identify secondary gains • Assertiveness training i: • Do not give lots of attention to symptoms • Encourage direct expression of feelings • Teach more helpful living • Rule out presence of physical illness

Illness Anxiety Disorder t:i

t: • Non-pharmacologic treatment of anxiety i: • Teach rational interpretation of body sensations • Encourage person to discuss feelings about their fears • Help connect stress and anxiety with exacerbation of physical symptoms.

Generalized Anxiety Disorder (GAD) T&i

t: • SSRI, Buspar, benzodiazepines • Cognitive therapy • Relaxation training i: • Encourage person to rethink perceptions of the stressors • Recognize that some anxiety is part of life • Teach how to cope

Acute stress disorder t&i

t: • Supportive • Anti-anxiety meds i: • Keep safe / Be supportive • Meet basic needs

Factious Disorder t&i

t: • Treat self-inflicted injury i: • Avoid confrontation. • Assess and document your care. • Carefully monitor and report any suspicious activities.

Illness Anxiety Disorder

• Characterized by EXTREME worry and fear that one has or will get a serious disease • Actual symptoms mild or absent • Obsessive and intrusive thoughts

Somatic Symptom Disorder

• Characterized by focus on somatic (physical) symptoms to point to excessive concern, preoccupation, and fear • Often generalized symptoms, unable to find biological cause for symptoms • High level of help seeking - rarely alleviates concerns

Factious Disorder

• Consciously pretend to be ill to get emotional needs met & attain status of patient • May fabricate symptoms or self-inflict injury • Imposed on Self OR Imposed on Another

Conversion disorder

• Manifests as neurological symptoms in absence of neurological diagnosis • Unexplained, usually sudden deficit in sensory or motor function such as blindness or paralysis • La belle indifference

Posttraumatic stress disorder (PTSD)

•After a traumatic event, re-experiencing it through dreams or flashbacks •Think TRAUMA (Traumatic event, Re-experience, Avoidance, Unable to function, Month (1+), Arousal) •Use denial, repression, and suppression to avoid anxious feelings •New behaviors developed related to the traumatic event •Trouble sleeping, depression and substance abuse

Generalized anxiety disorder (GAD)

•Difficulty controlling unrealistic, excessive anxiety associated with common daily experiences •Has lasted longer than 6 months •Three or more of the following symptoms: restlessness, irritability, muscle tension, fatigue, difficulty concentrating/thinking, and sleep alterations.