Question 1

A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?

Accepted Answer

The nurse should first lower the patient's current anxiety because severe anxiety can impair the patient's ability to learn and process new information.

Question 2

A patient in the emergency department shows disorganized behaviour and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?

Accepted Answer

An interview room with minimal furniture is the safest and most appropriate setting for managing a patient exhibiting disorganized behavior, as it reduces the risk of harm and distractions.

Question 3

A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?

Accepted Answer

The most appropriate nursing intervention in this situation is to present the information again in a calm manner using simple language. This will help the patient understand what they need to know about the surgery and reduce their anxiety. Simply reassuring the patient or encouraging them to express their feelings to family may not address their understanding of the preoperative information. Telling the patient that staff is prepared to promote recovery may not address their anxiety or understanding of the surgery.

Question 4

A patient undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defence mechanism is the patient using?

Accepted Answer

The patient is using denial as a defense mechanism by refusing to acknowledge the seriousness of their symptoms and attributing them to a minor issue like a chest cold.

Question 5

A patient fearfully runs from chair to chair, crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority?

Accepted Answer

The patient's behavior of running around and not following staff instructions puts them at high risk for injury. This should be the highest priority nursing diagnosis to ensure the safety of the patient.

Question 6

A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating which of the following?

Accepted Answer

Reaction formation is when a person behaves in a way that is opposite to what they truly feel, often to hide their true feelings. In this case, the person is likely masking jealousy or dislike with exaggerated affection.

Question 7

A patient fearfully runs from chair to chair, crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to do which of the following?

Accepted Answer

The highest priority is to ensure the patient's safety, as their behavior indicates they may be at risk of harming themselves or others due to their fear and agitation.

Question 8

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be which of the following?

Accepted Answer

This response encourages the patient to express their feelings more clearly, which can help in understanding and addressing their anxiety.

Question 9

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counselling demonstrates principles of which of the following?

Accepted Answer

Cognitive restructuring involves challenging and changing unhelpful thoughts and beliefs. In this case, the nurse helps the patient evaluate the likelihood of a fire, which is a cognitive approach to address the obsessive thought.

Question 10

A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?

Accepted Answer

Talking about feelings and concerns can help the patient feel less overwhelmed and begin problem-solving. It can also provide an opportunity for the nurse to validate the patient's emotions and provide support.

Question 11

A person has minor physical injuries after an auto 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 the person's level of anxiety?

Accepted Answer

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 will demonstrate markedly disturbed behavior and may lose touch with reality.

Question 12

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defence mechanism is evident?

Accepted Answer

The individual is using rationalization by creating a seemingly logical reason (partner's unattractiveness and lack of romance) to justify their own sexual dysfunction, rather than addressing the underlying issue.

Question 13

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety?

Accepted Answer

Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

Question 14

A patient tells a nurse, "I was not able to write my final exam as I had a pounding headache and I was not able to read." This patient is demonstrating which of the following?

Accepted Answer

Conversion disorder involves the expression of psychological distress through physical symptoms, such as headaches or inability to read, without a medical cause.

Question 15

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defence mechanism is evident?

Accepted Answer

Projection is a defense mechanism where an individual attributes their own unacceptable thoughts or feelings to someone else. In this case, the nurse is attributing the reason for not being promoted to the nurse manager's headache, rather than considering their own performance or qualifications.

Question 16

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic?

Accepted Answer

Lorazepam (Ativan) is a benzodiazepine, which is effective for rapid relief of acute anxiety symptoms.

Question 17

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of which of the following?

Accepted Answer

Compensation is a defense mechanism where an individual emphasizes strengths to make up for perceived weaknesses. In this case, the person is focusing on being smart to compensate for feeling unattractive.

Question 18

Which is an intermediate indicator of the nursing outcome of anxiety self-control?

Accepted Answer

The answer of Which is an intermediate indicator of the...

Question 19

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?

Accepted Answer

Generalized anxiety disorder is characterized by excessive worry or anxiety that is difficult to control. Therefore, asking if the patient finds it difficult to control their worrying is the most appropriate question to assess for this disorder. The other options are more relevant for post-traumatic stress disorder (A), social anxiety disorder (B), and obsessive-compulsive disorder (C).

Question 20

Two staff nurses applied for promotion to nurse manager. The day of the job interviews, one nurse was told by her boyfriend that he wanted to end the relationship. Although visibly upset, the nurse does not think about what her boyfriend has said and prepares for the interview. Which term best describes the nurse's response?

Accepted Answer

Suppression is a conscious decision to delay paying attention to a thought, emotion, or need in order to cope with the present situation, which is what the nurse is doing by not thinking about her boyfriend's statement and focusing on the interview.

Quiz 12: Anxiety and Related Disorders