Nokea
A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate?
- A. Reassure the patient that all nurses are skilled in providing postoperative care.
- B. Describe the procedure again in a calm manner, using simple language.
- C. Tell the patient that the staff is prepared to promote recovery.
- D. Encourage the patient to express feelings to his or her family.
Correct Answer: B
Rationale: Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the incorrect options will further scatter the patient's attention.
You may also like to solve these questions
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 person who feels unattractive repeatedly says, 'Although I'm not beautiful, I am smart.' This is an example of which defense mechanism?
- A. Repression
- B. Devaluation
- C. Identification
- D. Compensation
Correct Answer: D
Rationale: Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.
A child is placed in a foster home after being removed from parental contact because of both physical and verbal abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help minimize the child's anxious behaviors. What should the nurse recommend?
- A. Use a calm manner and low voice.
- B. Maintain simplicity in the environment.
- C. Avoid repetition in what is said to the child.
- D. Minimize opportunities for exercise and play.
- E. Explain and reinforce reality to avoid distortions.
Correct Answer: A,B,E
Rationale: The child can be hypothesized to have moderate-to-severe anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns.
A patient with a high level of motor activity runs from chair to chair and cries, 'They're coming! They're coming!' The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to:
- A. provide for patient safety.
- B. increase environmental stimuli.
- C. respect the patient's personal space.
- D. encourage the clarification of feelings.
Correct Answer: A
Rationale: Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.
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.