Question 1

A patient is seeking treatment for her fear of cats;even a picture or a thought of a cat causes her to sweat,tremble,become very apprehensive and uncomfortable,and become sick to her stomach.The nurse has established the nursing diagnosis as Anxiety related to exposure to phobic object (cats).A realistic indicator for the outcome Anxiety self-control would be that within 10 days,the patient will:

Accepted Answer

When the patient is able to relax in the presence of thoughts,pictures,or the phobic object,the patient will begin to experience a sense of control over the phobia.Given the prevalence of cats in our society,avoidance is not a realistic expectation,and attempting to avoid cats altogether would significantly restrict the patient in everyday life.Facing the feared object without supportive assistance is a desirable outcome but is not a realistic expectation within the first 10 days of treatment.The patient is already aware that her fear of cats is irrational and inappropriate;that awareness has led the patient to seek treatment.Intellectual understanding does not automatically convey the ability to change behavior or eliminate anxiety.

Question 2

A patient is scheduled to undergo a biopsy of a mass in his lung tomorrow morning.He seems to have difficulty grasping the procedure as the nurse explains it to him and repeatedly asks questions such as "What do you mean I'm going to have surgery? What are they going to do?" His voice is tremulous.His respirations are 28/minute,and his pulse is 110/minute.Which of the following initial outcome indicators would be most appropriate?

Accepted Answer

At this stage,the nurse's objective is to help the patient understand the procedure he is about to undergo.It appears that anxiety is interfering with his ability to understand the procedure.Therefore an indication of reduced anxiety that relates to the nurse's objective is that the patient is able to understand the procedure.Restoring vital signs to normal range and the patient being able to identify coping strategies are also desirable but are not the initial outcomes being sought at this time.Further,the patient is likely to remain anxious sufficiently to elevate his vital signs until the procure is completed and perhaps until he begins to cope with the results of the procedure,so restoring vital signs to his normal range is probably not realistic at this time (maintaining them at safe levels would,however,be an appropriate outcome).Accepting a cancer diagnosis would be inappropriate unless cancer has been confirmed.

Question 3

A man checks that his doors are locked two or more times each time he leaves home.The door is always found to be locked.Which of the following initial interventions would most likely be useful to this patient?

Accepted Answer

Cognitive restructuring involves identifying and questioning automatic thoughts and reframing (rewording)them in ways that are more accurate or more based in reality.In this instance,it is likely that the man is thinking that he may have left the door unlocked and that he will be robbed if he does not catch and correct his error.Replacing this thought with a more accurate statement (e.g. ,while it is possible he has overlooked locking the door,this is almost never the case,and he has never found the door unlocked after checking it once)can allow him to decide to skip the second door check.Noting that the behavior is irrational and has consequences is unlikely to be beneficial.It is likely that on some level,the patient already appreciates the irrationality and problems associated with the behavior (otherwise he would not have complained about it or sought help for it).While one could require him to skip the door checks repeatedly until experience convinces him that no harm would come from doing so,this would heighten his anxiety in the near term and likely would not be as effective as changing the thought that underlies this behavior in the first place.Having him check the door multiple times might be a form of flooding,but this would be more appropriate for reducing phobias than for obsessive thoughts or compulsive behaviors.

Question 4

A patient with moderate to severe anxiety associated with generalized anxiety disorder can be assessed as successfully lowering her anxiety level to mild when she:

Accepted Answer

The ability to concentrate and attend to reality and external events or stimuli is decreased in moderate,severe,and panic-level anxiety but increased slightly in mild anxiety.Asking "What's the matter with me?" in a pressured or excited manner suggests that her anxiety is at a moderate or severe level.Withdrawal,repetitive or rhythmic behavior,and motor restlessness also suggest moderate or severe anxiety.Interest in eating is variable in anxious persons and change in interest in intake is not reliably associated with any particular level of anxiety.

Question 5

A patient with chronic obstructive pulmonary disease is hospitalized for respiratory distress and has improved.She becomes very anxious when experiencing shortness of breath.One evening she is found to be restless and disorganized in her behavior and conversation.Which of the following should be considered first in determining the possible causes of these changes?

Accepted Answer

Hypoxia can mimic anxiety by causing restlessness,purposeless or repetitive activity,disorganization,and confusion.Persons with chronic obstructive pulmonary disease are often anxious about shortness of breath and the impact of their illness on their future health and independence,but because hypoxia presents a risk to the patient's health and safety,this potential cause of the patient's presentation should be considered first.Dementia develops slowly,unlike the acute mental status changes seen here.

Question 6

A patient with an intense fear of cats reports that after 2 weeks of therapy,she no longer sweats or becomes nauseated when she sees a cat on television but still cannot be in the same room with a cat.The nurse would interpret this change as meaning that the patient:

Accepted Answer

Improvement occurs incrementally,and expected outcomes should be structured to break the ultimate goal into smaller goals,each to be met in turn.In this case,the patient notes improvement in her physiological response to the phobic object,suggesting that her sympathetic nervous system is no longer becoming as aroused on exposure to cats.This is a significant sign of improvement and suggests that the patient is responding well to treatment,although with room for continued improvement.Given the prevalence of cats in our society,not being able to tolerate brief exposure to cats might inhibit her socialization;therefore,expecting to be able to tolerate the presence of a cat is not an unrealistic expectation.

Question 7

A patient who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse,"I know it's probably crazy,but I just can't bring myself to leave my apartment alone.And I can't expect somebody to take me to work every day." The nurse can make the assessment that the patient is:

Accepted Answer

The patient recognizes that it would not be unsafe to leave his home but is nonetheless afraid to do so.He is aware that his fear is inappropriate and unrealistic.The patient is interpreting reality appropriately,and there are no indications that the patient is attempting to elicit sympathy or attention from the nurse or experiencing depersonalization (feelings of unreality or alienation).

Question 8

A patient who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse: "I feel really stupid,a grown man not being able to leave his house." The most therapeutic reply is:

Accepted Answer

Acknowledging the patient's feelings by paraphrasing his comment ("You feel stupid because you're afraid to leave home?")shows that the nurse is listening,validates the nurse's understanding of his concern,and prompts the patient to elaborate further about his feelings."I don't think it's stupid…" implies that what the patient feels is wrong and he should not feel the way he does;this is a disconfirming (nontherapeutic)statement.Noting that the patient is not alone can reduce isolation if present but does not address the reported feeling."I can see how you might feel that way" in effect reinforces the patient's negative self-appraisal and is also nontherapeutic.

Question 9

A nursing student asks to be excused from a required group presentation.He reveals that he is afraid that he will "mess up" and that others will laugh at him.He reports significant dread at the thought of any public presentation,accompanied often by nausea and vomiting when such situations occurred in the past.He reports he was unable to go to prom because he cannot dance well and feared he would be teased or become physically ill.This history suggests the presence of a:

Accepted Answer

Fear of a potentially embarrassing situation and being judged by others is characteristic of a social phobia.Specific phobias involve being afraid of specific objects or circumstances,such as dogs or enclosed spaces.Here,the student instead fears any situation that involves being before others and in which he may be judged by others.Agoraphobia is fear of open places or being unable to escape or get help.Generalized anxiety disorder involves heightened anxiety in general,without a specific focus or precipitant.

Question 10

A patient is hospitalized for acute respiratory distress related to pneumonia and has improved.On admission she had been very anxious because she could not get her breath.On the night shift,she is found to be restless and disorganized in her behavior and conversation.Which of the following nursing interventions should be implemented first?

Accepted Answer

Hypoxia can cause mental and behavioral changes that can be mistaken for anxiety,including restlessness,disorganization,and confusion.Therefore,further assessment is needed before assuming that the signs noted here are due to anxiety.A simple check for hypoxia is pulse oximetry,and this should be checked immediately any time hypoxia is a possibility.It would be premature to attempt any of the other interventions here until hypoxia was ruled in or out as the likely cause of this patient's presentation.

Question 11

A famous general sometimes slowed down his entire army because he felt he must count all the windows in each of the buildings he passed.A patient feels that he must repeat washing his hands three times each time he washes.The nurse recognizes that such behaviors serve the purpose of reducing:

Accepted Answer

The behaviors described here are compulsions.Persons demonstrating such behaviors feel compelled to take such actions and experience distress (or will not experience relief from distress)until they do.Compulsions serve the purpose of temporarily relieving anxiety.Obsessions may involve sexual themes,but the purpose of compulsions is to relieve anxiety.Guilt may be also be obsessive in nature,but compulsive behavior does not relieve guilt.Repetitive behavior can increase one's sense of security temporarily but does not reduce uncertainty or confusion.

Question 12

A soldier serving in the Middle East was in a convoy when an improvised explosive device (IED)killed three fellow soldiers in the vehicle in front of hers.Five weeks later,she began to report intrusive thoughts of missiles screaming toward her and exploding,and loud sounds began to trigger an involuntary re-experiencing of the IED explosion.Three months later,she reported continuing sleep impairment,nightmares,social withdrawal,disrupted relationships,and flashbacks.This soldier's presentation most suggests:

Accepted Answer

DSM-IV-TR criteria for posttraumatic stress disorder is most consistent with the soldier's presentation.The symptoms noted are not part of the clinical manifestations of pathological grief,panic disorder,or agoraphobia.Acute stress disorder has many symptoms in common with posttraumatic stress disorder,but the criteria for this disorder specify that the symptoms begin soon after the traumatic event and do not extend beyond 4 weeks after the event.

Question 13

A patient who has been unable to leave his home for more than a month because of symptoms of severe anxiety tells the nurse,"I know it's probably crazy,but I just can't bring myself to leave my apartment alone." An appropriate nursing intervention for the nurse to include in the initial nursing care plan is:

Accepted Answer

This intervention,a form of cognitive restructuring,replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I am scared but I know that I am safe despite my fear,and if I do my deep breathing I can control my anxiety." This technique helps the patient gain mastery over his symptoms.A person unable to leave his home would be unable to access support groups or other treatment in the community.Pointing out the irrationality of his fears would be unproductive,since the patient is already aware of their irrationality.This awareness alone is not enough to change the fear.Medications play an important role,but there are many other actions the patient can take to improve coping,and the medications alone are not likely to be as effective as they would be if combined with other efforts to decrease anxiety and enhance coping.

Question 14

A patient who has been pacing rapidly for the past hour cannot immediately be located on the unit.When he is found,he is in his closet,rocking back and forth rapidly and talking rapidly to himself.When staff approach,he only seems to notice them momentarily,then leaves his room and begins running up and down the hallway.Which of the following interventions should be attempted at this point?

Accepted Answer

The patient's behavior is consistent with a panic level of anxiety.Calm,brief,directive verbal instructions can help such patients gain control of overwhelming feelings and impulses.Patients experiencing panic-level anxiety are unable to focus and integrate new information into memory,making teaching likely to be ineffective until their anxiety is reduced.Antianxiety medications and seclusion would be a back-up intervention if verbal interventions fail.However,although providing an opportunity for the patient to participate in decisions about his care is usually desirable,asking the patient to choose the route of medication to be used at a time when understanding and decision making are impaired is not therapeutic.Seclusion could be interpreted as punishment or perceived as a threat,and in turn heighten his fear and panic;it should be reserved for situations when all other options have failed or no other intervention can provide acute safety needs.

Question 15

When interviewing and planning care for a patient with fear of public speaking,the nurse must be aware that social phobias are often treatable with:

Accepted Answer

Beta-blockers such as propranolol dampen sympathetic nervous system activity and are often effective in preventing symptoms of anxiety associated with social phobias.Neuroleptics are antipsychotic drugs,and social phobias are not psychotic disorders.Tricyclic antidepressants are rarely used,because of their side-effect profiles.Monoamine oxidase inhibitors are used for depression and only by individuals who can observe the special diet required.

Question 16

The nurse caring for a patient who has been diagnosed as having generalized anxiety disorder tells a preceptor,"I find myself feeling uncomfortable and anxious around the patient.When he starts trembling and perspiring and pacing,I find myself with cold,clammy hands,and my pulse races.I start worrying whether I will be able to help him stay in control." In such an interaction,the patient will most likely experience:

Accepted Answer

Anxiety is transmissible interpersonally,and nurses working with anxious patients may find themselves feeling more anxious as well.Conversely,anxiety in the nurse can be conveyed to the patient,increasing the patient's anxiety.Claustrophobia is a specific phobia usually occurring as a result of personal experience,rather than deriving from another person's communicated anxiety.Acute stress disorder stems from exposure to an acute,anxiety-inducing event.Impaired self-esteem,while possibly developing as a consequence of some anxiety disorders,is not likely to occur as a result of working with an anxious nurse.

Question 17

When a patient asks what causes his panic attacks,the nurse should reply that research gives evidence to support the theory that panic disorders have their etiology in:

Accepted Answer

Panic attacks can be caused by the introduction of various chemicals into the body,thus supporting a biological theory of etiology.Patients experiencing panic attacks frequently have close relatives who experience panic attacks,a finding that suggests a genetic tie.Theories suggesting that psychological conflicts,trauma,or developmental issues contribute to panic disorder have not been well supported by research.

Question 18

A patient tells the nurse that she wants her physician to prescribe diazepam (Valium)for anxiety reduction.The physician has prescribed buspirone (BuSpar).The nurse's reply should be based on the knowledge that buspirone:

Accepted Answer

Buspirone is considered effective in the long-term management of anxiety because it is effective at relieving anxiety and is not habituating.However,because it has a relatively slow onset of action (slower than benzodiazepines)and is long acting,it is not appropriate as a PRN medication or a fast-acting medication.Benzodiazepines are unlikely to increase risks of blood dyscrasias.

Question 19

For the patient whose nursing diagnosis is Powerlessness related to an inability to control compulsive cleaning,the nurse must understand that the patient uses the cleaning to:

Accepted Answer

The primary gain achieved from the patient's use of these rituals is anxiety relief.Unfortunately,the anxiety relief is short lived,and the patient must frequently repeat the ritual.Cleaning may give the patient a sense of accomplishment,distract her temporarily,or reduce the risk of contagious disease spread,but these are not the primary reasons persons with obsessive-compulsive disorders engage in their rituals.

Question 20

A patient who is a recovering alcoholic has been diagnosed as having panic attacks.The psychiatrist mentions plans to treat the patient with daily doses of medication.Of the medications listed below,for which drug should the nurse plan patient teaching?

Accepted Answer

Selective serotonin reuptake inhibitors are first-line drugs for the treatment of panic disorder.Both paroxetine and sertraline are approved by the U.S.Food and Drug Administration for treatment of panic disorder.Selective serotonin reuptake inhibitors are nonaddicting and have a relatively low incidence of unpleasant side effects.Also useful are tricyclic antidepressants,such as imipramine,which are more useful than the benzodiazepines,because they are nonaddicting.Alprazolam is a benzodiazepine and as such is prone to abuse and can cause addiction;it would not be the drug of choice for a patient who has a problem of chemical dependency.Chlorpromazine is a neuroleptic and not useful for treating panic disorder.Propranolol is more often used in the treatment of social phobias.

Quiz 12: Anxiety and Anxiety Disorders