Nokea
A person has minor physical injuries after an automobile accident. The person is unable to focus and says, 'I feel like something awful is going to happen.' This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: C
Rationale: The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic-level anxiety demonstrates significantly disturbed behavior and may lose touch with reality.
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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.
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 experiencing severe anxiety suddenly begins running and shouting, 'I'm going to explode!' The nurse should implement which intervention to best maximize the patient's safety?
- A. State, 'I'm not sure what you mean. Give me an example.'
- B. Chase after the patient while giving instructions to stop running.
- C. Retrain the patient in a basket-hold to increase feelings of control.
- D. Assemble several staff members and state, 'We will help you regain control.'
Correct Answer: D
Rationale: The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.
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 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.