Nokea
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.
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A patient in the emergency department has no physical trabaja injuries but exhibits disorganized behavior and incoherence after a minor traffic accident. In which room should the nurse place the patient?
- A. Interview room furnished with a desk and two chairs.
- B. Small, empty storage room with no windows or furniture.
- C. Room with an examining table, instrument cabinets, desk, and chair.
- D. Nurse's office, furnished with chairs, files, magazines, and bookcases.
Correct Answer: A
Rationale: Individuals who are experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.
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 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 performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies?
- A. Allow the patient to set a hand-washing schedule.
- B. Encourage the patient to participate in social activities.
- C. Encourage the patient to discuss hand-washing routines.
- D. Focus on the patient's symptoms rather than on the patient.
Correct Answer: B
Rationale: Because patients diagnosed with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient's coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.
Which assessment questions are most relevant to ask a patient with possible obsessive-compulsive disorder?
- A. Have you been a victim of a crime or seen someone badly injured or killed?
- B. Are there certain social situations that cause you to feel especially uncomfortable?
- C. Do you have to do things in a certain way to feel comfortable?
- D. Is it difficult to keep certain thoughts out of awareness?
- E. Do you do certain things over and over again?
Correct Answer: C,D,E
Rationale: The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social anxiety disorder (social phobia).