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Fortinash: Psychiatric Mental Health Nursing, 5th Edition Chapter 10: Anxiety and Anxiety Disorders (27) MULTIPLE

CHOICE 1. A patient who was savagely attacked by a bear has no memory of the event. Which statement best explains the patients inabili ty to remember the attack? a. The woman lost consciousness and was not cognitively aware of what happened during the attack b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely. c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack. d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories. ANS: C Defense mechanisms are used unconsciously to protect us from threats to the physical, mental, and social aspects of ourselves. The memory of the event may or may not come back but this is not generally related to the patients ability to handle the memories. Memory may be lost or impaired as a result of brain trauma but not as likely from a chemical alteration. DIF: 2. a. b. c. d. Cognitive Level: Application REF: Page 187

Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder (PTSD) would be considered a defining behavior and support such a diagnosis? Can describe the attack in great detail Experiences dramatic swings in affect Describes vivid flashbacks of being attacked Is preoccupied with the need to tell someone about the attack

ANS: C One defining behavior that is seen when an individual has PTSD is that the person re-experiences the traumatic event. This takes place by having recurrent and intrusive disturbing recollections of the trauma, including thoughts, images, or perceptions about the incident. The person sometimes experiences recurrent dreams of the incident and acts or feels as though the event was recurring in the present (flashback). Generally the PTSD patient cannot remember all the details of the trauma nor are they particularly interested in re-telling the events of the trauma. The patient generally has a very limited range of affect. DIF: 3. a. b. c. d. Cognitive Level: Application REF: Page 196

What is the basis for assessing a male patient who is agoraphobic for panic attacks? Men are more likely to experience panic attacks. An overwhelming number of agoraphobic patients also have panic attacks. Patients are often unaware that the symptoms they are experiencing are those of panic. Panic attacks are generally the cause of a patient developing phobias like agoraphobia.

ANS: B Almost all patients who present with agoraphobia in clinical samples have a current diagnosis or history of panic disorder. Males are not more likely than females to experience panic attacks. Patients are not usually unaware of panic attack symptoms. Panic attacks dont cause, but are often triggered by, phobias. DIF: 4. a. b. c. d. Cognitive Level: Application REF: Page 193

Discharge preparation for a patient includes the administration of the Hamilton Anxiety Scale (HAS). When asked by the patient to explain the purpose of the assessment the nurse responds: It is an assessment tool used to evaluate the symptoms of anxiety. The tool is used to help confirm the diagnosis of anxiety disorder. This tool helps determine if your symptoms have improved with treatment. It helps identify the presence of any other disorder associated with anxiety.

ANS: C The HAS is a valid and time-tested tool that gives the most objective measure of the degree to which anxiety has been effectively treated. The HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated disorder. DIF: 5. a. b. c. d. Cognitive Level: Application REF: Page 202

A patient is admitted for treatment for persistent, severe anxiety. Which nursing diagnosis would help effectively direct patient care? Disturbed sensory perception related to narrowed perceptual field Risk for injury related to closed perception Hopelessness related to total loss of control Risk for other-directed violence related to combative behavior

ANS: A A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses. DIF: 6. Cognitive Level: Analysis REF: Page 189

a. b. c. d.

The patient was an awkward child who was ridiculed by his father for his inability to catch a ball. As an adult, the patient developed panic attacks at the time his company established after-work team sporting activities. Which data discussed during the nursing interview provides insight to the possible cause of this anxiety disorder when applying the behavioral model? He always avoids sports because Im short and not the least bit athletic. When in fifth grade, the patient caused his team to lose the big softball game. The company he works for places tremendous emphasis of successful team work. As a child he wore a leg brace that prevented him from participating in school sports.

ANS: A In behavioral models that are based on learning theory, the etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or object. As a result, he associates embarrassment and shame with sports events and develops panic attacks. The same kinds of cognitive operations that link embarrassment with sporting events link the cognition of the expectation of embarrassment with the idea of a sporting event, and the individual begins to experience panic attacks while merely thinking about being involved. The remaining options are not as likely to bring about the embarrassment and shame that would produce such a response. DIF: 7. a. b. c. d. Cognitive Level: Application REF: Page 192

The nurse is working with the family of a patient with obsessive-compulsive disorder (OCD). Which concept should the nurse incorporate in the teaching plan? The thoughts, images, and impulses are voluntary. The family should pay immediate attention to symptoms. The thoughts, images, and impulses tend to worsen with stress. OCD is a chronic disorder that does not respond to treatment.

ANS: C Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the patients life as much as possible. The symptoms are not under the patients voluntary control. It is nontherapeutic to immediately focus on the symptoms, since to do so contributes to secondary gain. OCD responds well to medication and therapy. DIF: Cognitive Level: Application REF: Page 198 TOP: Nursing Process: Planning

8. a. b. c. d.

Which question would assist the nurse in determining whether the patient has been experiencing anxiety? Have you had difficulty concentrating lately? Have you been feeling sad and especially lonely? Do you have a history of failed personal relationships? Do you frequently experience difficulty controlling your anger?

ANS: A Concentration difficulties occur when moderate or greater levels of anxiety are present. Loneliness is more related to mood. A failed personal relationship is more related to poor self-esteem. Inability to control anger is related to poor impulse control. DIF: 9. a. b. c. d. Cognitive Level: Application REF: Page 197 | Page 199

The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patients increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety? Talking rapidly Pacing around the unit Staring out the window Refusing to go to therapy

ANS: B Recognize the patients use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients. DIF: Cognitive Level: Application REF: Page 200

10. The nurse has been working with a patient who experiences anxiety. Which intervention should the nurse implement initially when the patient is observed pacing and wring her hands?

a. b. c. d.

Asking how she has managed anxiety effectively in the past Distracting her by offering to help her make a telephone call Asking her what she believes is causing her increased anxiety Teaching her to take deep, relaxing breaths to manage the anxiety

ANS: A First help the patient to build on the coping methods that the patient used to manage anxiety in the past. Coping methods that were previously successful will generally be effective in subsequent situations. Distraction is not usually successful initially. Assessing for the cause of the anxiety will not, in this situation, be helpful in managing it; often times patients are not aware of the cause. Teaching will not be effective while the patient is experiencing anxiety but should be done when the patient is relaxed and able to focus. DIF: Cognitive Level: Analysis REF: Page 200

11. The nurse is working with a patient with an anxiety disorder whose treatment includes cognitive behavioral therapy. Which statement by the patient gives the nurse reason to assume that the patient has an understanding of the basis of this type of therapy? a. My abusive childhood has resulted in my overreaction to stress. b. My delusional thoughts of extreme anxiety are what cause my panic attacks. c. My brain chemistry causes me to overreact to common stress by getting so anxious. d. Ive learned to react to my daily stress by having anxious thoughts and panic attacks. ANS: D The success of this approach centers on the patients understanding that the symptoms are a learned response to thoughts or feelings about behaviors that occur in daily life. Cognitive therapy helps patients identify target symptoms and change the cognitions associated with them. This is a psychodynamic model explanation. Anxiety disorders have no relationship to delusions. Brain chemistry is not a usual cause of anxiety but rather can be altered by anxiety. DIF: 12. a. b. c. d. Cognitive Level: Application REF: Page 201

Which verbal intervention would the nurse use when helping a patient who is experiencing severe to panic-level anxiety? I will stay with you to make sure you remain safe. First, you must stop pacing and wringing your hands. How can I help you get control of yourself and this anxiety? Can you tell me what was happening just before you got upset?

ANS: A A patient who is experiencing severe to panic-level anxiety requires brief, directive verbal interchanges aimed at increasing feelings of safety and security. It is not likely the patient will be able to stop the physical behaviors. Severely anxious patients are not able to evaluate their situation and give direction to the nurse or are they able to relate antecedent events to increasing anxiety. DIF: Cognitive Level: Application REF: Page 200

13. The nurse notes that a patient being treated for an anxiety disorder is becoming more anxious sitting in a congested, noisy room waiting to see the therapist. Which intervention will the nurse implement initially to assist the patient in de-escalating his anxiety? a. Offering to reschedule the patients appointment b. Taking the patient to an unoccupied interview room c. Notifying the therapist of the need to see the patient stat d. Requesting oral prn anxiolytic medication for the patient ANS: B A congested, noisy environment is not conducive to maintenance of low anxiety. Moving the patient to a less stimulating environment may be all that is needed for the patient to lower his anxiety level. The other options may not be necessary if the nurse intervenes effectively. DIF: Cognitive Level: Application REF: Page 201 14. A patient is ordered medication therapy to manage the symptoms of anxiety disorder. Which statement by the patient indicates an understanding of the typical classification of medication prescribed for this disorder? a. Tricyclic antidepressants are particular good for panic attacks. b. I have to give up beer while taking monamine oxidase inhibitors (MAOIs). c. Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well. d. Benzodiazepines are usually effective when taken for chronic anxiety like mine. ANS: C SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. Tricyclic antidepressants are not effective for panic attacks and have more side effects than SSRIs. MAOIs are effective but require knowledge of and compliance with a special diet and are not the first choice in this situation. Benzodiazepines are effective but produce alterations in sensorium and other side effects and are not used for long-term management.


Cognitive Level: Application


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15. A patient with OCD tells the nurse, Thinking these thoughts and doing all my rituals is beyond being sil ly. I have few friends and I know others laugh behind my back. I sometimes think I can control things, but I always find I cant. I dont know if I can co ntinue to live this way. Which assessment question shows the nurse has an understanding of this patients priority risk? a. Are you feeling hopeless? b. Do you think you are socially isolated? c. Have you been thinking about hurting yourself? d. Do the rituals affect how you feel about yourself? ANS: C Patients with anxiety disorders should always be assessed for the presence of depression and suicidal ideation, the priority risk to safety. This patient has admitted feeling powerless to control the symptoms, in addition to wondering if she can continue to live the way she has been. There is ample reason for asking about suicidal ideation. The remaining options address hopelessness, social isolation, and low selfesteem. While appropriate nursing concerns, they dont have the priority self-harm has for this patient. DIF: Cognitive Level: Analysis REF: Page 199

16. The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, You will need to assess for acute stress reactions as well as treating physical problems. Which patient is exhibiting symptoms characteristic of acute stress reaction? a. A male whose moods swing between mania and depression b. A female who reports still hearing her daughters pleas for help c. A male who keeps repeating I dont understand whats going on? d. A female who is rocking her young son and repeating it will be okay. ANS: C Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction. DIF: Cognitive Level: Application REF: Page 196

17. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patients family member reports that the nurse curtly told them You cant come in now. You know you need to wait until visiting hours. The incidence should be discussed based on the knowledge that the defense mechanism the nurse used was: a. Displacement b. Projection c. Sublimation d. Suppression ANS: A Displacement is transferring a response or feeling toward one person onto another less threatening person. Projection is attributing strong faults to another and is not displayed in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors. Suppression is intentionally avoiding thinking about problem areas. DIF: Cognitive Level: Comprehension REF: Page 188

18. During a nursing assessment, a teenage patient smiles and states, I dont care what you say. I want to be just like Mike, th e leader of our gang. The nurse understands the defense mechanism being used is: a. Denial b. Humor c. Splitting d. Identification ANS: D Identification is wishing or trying to be like someone else. Denial is an unconscious refusal to acknowledge some reality. Humor is not being used. Splitting is viewing oneself and others as all bad or all good. DIF: Cognitive Level: Comprehension REF: Page 188

19. A young, married female patient is attracted to a male nurse. When the nurse sets clear boundaries, the patient falsely accuses him of sexual harassment. The nursing supervisor recognizes the defense mechanism of: a. Projection b. Splitting c. Suppression d. Displacement

ANS: A Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario. DIF: Cognitive Level: Comprehension REF: Page 188

20. A college-aged patient complains that, when I begin to take a test, I freeze up and my mind goes blank. The nurse will react based on the understanding that this patients anxiety level is: a. Mild b. Moderate c. Severe d. Panic ANS: C In severe anxiety, a person may freeze and problem solving is difficult. A person is relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may feel energized and focused. A person at panic level has total loss of control. DIF: Cognitive Level: Comprehension REF: Page 189

21. A college student diagnosed with high levels of anxiety is being prepared for discharge. Which discharge criteria is appropriate for this patient? a. The patient will avoid situations that cause anxiety. b. The patient will use learned anxiety-reducing strategies. c. The patient will return to living at home with supportive parents. d. The patient will state, I know medication is what I need to control my anxiety. ANS: B Using anxiety-reduction strategies will promote maximal functioning. Trying to avoid stressful situations is impractical and encourages avoidance, therefore limiting activities and not supporting the development of coping mechanisms. Moving back into the parent s home promotes dependency, and medication therapy is not necessarily the only treatment for anxiety. DIF: Cognitive Level: Application REF: Page 198

MULTIPLE RESPONSE 1. a. b. c. d. e. A patient is being evaluated for a possible diagnosis of panic disorder with agoraphobia. Which nursing assessment findings support this diagnosis? Select all that apply. Patient states, Ive had these fears for more than 6 years. Patient describes having a panic attack several times a month. Patient is embarrassed by the limitations the disorder causes. Stated, I never even think about going shopping in a crowded mall. Condition began after beginning treatment for a chronic intestinal problem.

ANS: A, B, C, D To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person must experience recurrent, unexpected panic attacks, with at least one attack followed by one of the following for a month: (1) persistent concern about having additional attacks; (2) worry about the implications of the panic attacks; or (3) a significant change in behavior as a result of the attacks. The second criterion is that the individual experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third criterion is that the person avoids agoraphobic situations or has anxiety about having a panic attack. This person will not go to an area or event where he or she has experienced an agoraphobic reaction. The fourth criterion states that panic attacks are not caused by the direct effects of a substance, a medication, or a medical condition. DIF: 2. a. b. c. d. e. Cognitive Level: Analysis REF: Page 195

The nurse has identified a nursing diagnosis of disturbed thought processes for a patient with obsessive-compulsive disorder. What abilities displayed by the patient would be related to an appropriate outcome for this problem? Select all that apply. Can identify when obsessions are worsening Speaks of obsessions as being embarrassing behaviors Describes lessening anxiety when compulsive rituals are interrupted Plans to ignore obsessive thoughts and so minimizes resulting stress Limits time focusing on obsessive thoughts to 15 minutes, 4 times a day

ANS: A, C, E It is desirable for the patient to experience a sense of being able to identify and control the obsessive thinking and the resulting anxiety. Identifying the behaviors as embarrassing is not showing control nor is ignoring the behaviors. DIF: 3. a. b. c. d. e. Cognitive Level: Application REF: Page 200

Which lifestyle changes should the nurse incorporate in the nursing care plan for a patient with generalized anxiety disorder? Select all that apply. Stop smoking. Limit caffeine intake. Eliminate stress from your life. Practice a relaxation technique daily. Limit worrying to specific times each day.

ANS: A, B, D, E CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as heart rate and muscle tension. Relaxation techniques are invaluable in the management of stress and anxiety. Limiting the time to allow worrying will help control the invasive thoughts. One cannot avoid stressful situations and attempting to do so does not help in managing its affects. DIF: 4. a. b. c. d. e. Cognitive Level: Application REF: Page 200

A nursing interview for a patient being admitted for depression reveals that the patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by the nurse reflect an understanding of the effects of this classification of drugs? Select all that apply. The nurse asks how much of the drug the patient takes daily. The admitting physician is notified of the patients medication history. The nurse prepares to discuss the process of detoxification with the patient. The nurse suggests to the patient that the dosage is likely to be increased. The patient is interviewed regarding how well the anxiety has been controlled.

ANS: A, B, C Benzodiazepines are relatively safe and effective for short-term use to control the debilitating symptoms of anxiety. However, longer-term treatment with these drugs raises issues of tolerance, abuse, and dependence. The medication dosage would not be increased. The effectiveness of the medication is irrelevant but rather the length of the therapy is the prime concern. DIF: Cognitive Level: Application REF: Page 201


a. b. c. d. e.

A patient comes to the ED exhibiting severe physical and emotional symptomology. When no physical cause can be found for the symptoms, the patient is diagnosed with severe anxiety with panic attack symptoms. Which assessment data supports this diagnosis? Select all that apply. Blood pressure 158/90; 15 minutes later 130/80 Claims that she feels like she going to die Random but controlled thoughts Unable to follow instructions Dry, flushed skin

ANS: A, B, D Blood pressure will begin to drop in a panic attack as the sympathetic nervous system release occurs; the patient may express an emotional sensation of doom and the patient will not be able to concentrate and so will be unable to follow instructions. Thoughts during a panic attack are uncontrolled and the skin is diaphoretic. DIF: Cognitive Level: Analysis REF: Page 193

6. a. b. c. d. e.

Which considerations should a nurse include when conducting a mental health assessment on a culturally diverse patient Select all that apply. Men and women are equally likely to seek psychiatric health care. The role that spirits and magic play in a patients belief system is cultural based. Rituals are only deemed obsessive when applied to the patients cultural standards. Agoraphobia is more difficult to assess in cultures that restrict female socialization. The nurse should consider the universal application of the Diagnostic and Statistical Manual (DSM-IVTR).

ANS: B, C, D Some cultures restrict womens participation in public activities; thus agoraphobia is less commonly diagnosed. Fears of magi c and spirits are present in many cultures and are pathologic only when they are deemed excessive in the context of that culture. Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not indicative of OCD unless i t exceeds norms for that culture, is exhibited at times or places that are inappropriate for that culture, or interferes with social functioning. Most research that supports the development of the Diagnostic and Statistical Manual, ed 4, text revision (DSM-IVTR) classification occurred in the United States; consequently, symptoms that define disorders are representative of U.S. culture. Overall, women are more likely than men to present for treatment or to come in contact with health care providers. DIF: Cognitive Level: Application REF: Page 193