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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.
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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.
A patient has the nursing diagnosis anxiety as evidenced by an inability to control compulsive cleaning. Which phrase referring to the likely trigger correctly completes the etiological portion of the diagnosis?
- A. Ensuring the health of household members
- B. Attempting to avoid interactions with others
- C. Having persistent thoughts about bacteria, germs, and dirt
- D. Needing approval for cleanliness from friends and family
Correct Answer: C
Rationale: Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relieve anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.
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.
Which client statement most supports a diagnosis of agoraphobia?
- A. Being afraid to go out seems ridiculous, but I can't go out the door.
- B. I'm sure I'll get over not wanting to leave home soon. It takes time.
- C. When I have a good incentive to go out, I can do it.
- D. My family says they like it now that I stay home.
Correct Answer: A
Rationale: Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
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.