Nokea
Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?
- A. I check where my car keys are eight times.
- B. My legs often feel weak and spastic.
- C. I'm embarrassed to go out in public.
- D. I keep reliving the car accident.
Correct Answer: A
Rationale: Recurring doubt (obsessive worry) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, 'My legs feel weak most of the time,' is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.
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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 is undergoing diagnostic tests. The patient says, 'Nothing is wrong with me except a stubborn chest cold.' The spouse reports that the patient smokes, coughs daily, has recently lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
- A. Displacement
- B. Regression
- C. Projection
- D. Denial
Correct Answer: D
Rationale: Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.
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 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 person consistently rationalizes their cruel and abusive behavior. Which comment is most characteristic of this person defense mechanism?
- A. I don't know why it happens.
- B. I have always had poor impulse control.
- C. That person should not have provoked me.
- D. Inside I am a coward who is afraid of being hurt.
Correct Answer: C
Rationale: Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person.