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A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention?
- A. Offering hope allays and defuses the patient's anxiety
- B. Concerns stated aloud become less overwhelming and help decrease feelings of isolation
- C. Anxiety is reduced by focusing on and validating what is occurring in the environment
- D. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety
Correct Answer: B
Rationale: All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming, less socially isolating, and help problem solving to begin.
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A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder (GAD) who takes lorazepam. What information should be included?
- A. Use caution when operating machinery.
- B. Allow only tyramine-free foods in diet.
- C. Restrict intake of caffeine.
- D. Avoid using alcohol and other sedatives.
- E. Take the medication on an empty stomach.
Correct Answer: A,C,D
Rationale: Caffeine is a central nervous system stimulant that acts as antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.
A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to:
- A. verify the patient's learning style.
- B. create outcomes and a teaching plan.
- C. lower the patient's current anxiety level.
- D. assess how the patient uses defense mechanisms.
Correct Answer: C
Rationale: A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.
Which assessment question would be most appropriate for the nurse to ask a patient who is at risk for developing generalized anxiety disorder (GAD)?
- A. Have you been a victim of a crime or seen someone badly injured or killed?
- B. Do you feel especially uncomfortable in social situations involving people?
- C. Do you repeatedly do certain things over and over again?
- D. Do you find it difficult to control your worrying?
Correct Answer: D
Rationale: Patients with GAD frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.
A patient tells a nurse, 'My new friend is the most perfect person one could imagine - kind, considerate, and good looking. I can't find a single flaw.' This patient is demonstrating which defense mechanism?
- A. Denial
- B. Projection
- C. Idealization
- D. Compensation
Correct Answer: C
Rationale: Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.
A patient experiencing moderate anxiety says, 'I feel undone.' An appropriate response for the nurse would be:
- A. Why do you suppose you are feeling anxious?
- B. What would you like me to do to help you?
- C. I'm not sure I understand. Give me an example.
- D. You must get your feelings under control before we can continue.
Correct Answer: C
Rationale: Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.