Nokea
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).
You may also like to solve these questions
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.
A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, 'I've been working on other things.' When asked 4 hours later, the worker says, 'Someone else was using the copier, so I couldn't finish it.' The worker's behavior demonstrates the use of what mechanism?
- A. Acting out
- B. Projection
- C. Suppression
- D. Passive aggression
Correct Answer: D
Rationale: A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks. Acting out refers to behavioral expression of conflict. Projection is a form of blaming. Suppression is the conscious denial of a disturbing situation or feeling.
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.
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.
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.