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A student says, 'Before taking a test, I feel a heightened sense of awareness and restlessness.' What nursing intervention is most helpful for assisting the student?
- A. Explaining that the symptoms are the result of mild anxiety and discussing the helpful aspects
- B. Advising the student to discuss this experience with a health care provider
- C. Encouraging the student to begin antioxidant vitamin supplements
- D. Listening without comment
Correct Answer: A
Rationale: Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.
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Which assessment finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild?
- A. Patient asks, 'What's the matter with me?'
- B. Patient stays in a room alone and paces rapidly.
- C. Patient successfully concentrates on what the nurse is saying.
- D. Patient states, 'I don't want anything to eat. My stomach is upset.'
Correct Answer: C
Rationale: The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, 'What's the matter with me?' Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.
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.
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.
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 experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as a short-term therapy?
- A. Buspirone
- B. Lorazepam
- C. Amitriptyline
- D. Desipramine
Correct Answer: B
Rationale: Lorazepam is a benzodiazepine medication used to treat anxiety on a short-term basis only. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.