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A student says, 'Before taking a test, I feel a heightened sense of awareness and restlessness.' The nurse can correctly assess that the student's response is a result of what?
- A. Cultural influence
- B. Displacement
- C. Trait anxiety
- D. Mild anxiety
Correct Answer: D
Rationale: Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.
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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.
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 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.
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 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.