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A patient tells the nurse, 'I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at.' The nurse assesses this behavior as consistent with which mental health diagnosis?
- A. Acrophobia
- B. Agoraphobia
- C. Social anxiety disorder
- D. Posttraumatic stress disorder (PTSD)
Correct Answer: C
Rationale: The fear of a potentially embarrassing situation represents social anxiety disorder (social phobia). Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Posttraumatic stress disorder is associated with a major traumatic event.
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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.
For a patient experiencing panic, which nursing intervention should be implemented first?
- A. Teaching relaxation techniques
- B. Administering an anxiolytic medication
- C. Providing calm, brief, directive communication
- D. Gathering a show of force in preparation for gaining physical control
Correct Answer: C
Rationale: Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other, less-restrictive measures are proven ineffective.
A patient with a high level of motor activity runs from chair to chair and cries, 'They're coming! They're coming!' The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority?
- A. Risk for injury
- B. Self-care deficit
- C. Disturbed energy field
- D. Disturbed thought processes
Correct Answer: A
Rationale: A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of self-care deficit or disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.
A patient tells the nurse, 'I wanted my health care provider to prescribe diazepam for my anxiety disorder, but buspirone was prescribed instead. Why?' The nurse's reply should be based on the knowledge of which characteristic of buspirone?
- A. It does not produce blood dyscrasias.
- B. It is not known to cause dependence.
- C. It can be administered as needed.
- D. It is faster acting than diazepam.
Correct Answer: B
Rationale: Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone.
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.