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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.
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A patient approaches the nurse and impatiently blurts out, 'You've got to help me! Something terrible is happening. My heart is pounding.' The nurse responds, 'It's almost time for visiting hours. Let's get your hair combed.' Which approach has the nurse used?
- A. Bringing up an irrelevant topic
- B. Responding to physical needs
- C. Addressing false cognitions
- D. Focusing
Correct Answer: A
Rationale: The patient is experiencing anxiety. The nurse has closed off patient-centered communication by changing the subject. The introduction of an irrelevant topic makes the nurse feel better. The nurse may be uncomfortable dealing with the patient's severe anxiety. The nurse has not responded to the patient's physical needs. There is no evidence of false cognition. Focusing is a therapeutic communication technique used to concentrate attention on a single issue.
A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, 'What are they going to do?' Assessment findings on the patient include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats/min. What is the patient's level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: B
Rationale: Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.
A person who is speaking about a contender for a significant other's affection says in a gushy, syrupy voice, 'What a lovely person. That's someone I simply adore.' The individual is demonstrating what defense mechanism?
- A. Reaction formation
- B. Repression
- C. Projection
- D. Denial
Correct Answer: A
Rationale: Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.
Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response?
- A. Altruism
- B. Sublimation
- C. Suppression
- D. Passive aggression
Correct Answer: A
Rationale: Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse's reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.
An individual experiencing sexual dysfunction blames it on their partner and suggests the person is both unattractive and unromantic. Which defense mechanism is evident?
- A. Rationalization
- B. Compensation
- C. Introjection
- D. Regression
Correct Answer: A
Rationale: Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.