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Fortinash: Psychiatric Mental Health Nursing, 4th Edition Chapter 9: Anxiety and Anxiety Disorders 1. The nurse who follows the social psychiatry model of etiology of anxiety understands that the four stages of anxiety are explainable as: 1. Individual responses to the environment ranging along a continuum from adaptive to formation of symptoms of mental or physical illness 2. A generalization from an earlier traumatic experience to a benign setting or object that can be modified by new learning 3. A genetically predetermined response to environmental stress 4. Related to degrees of warning to the ego that it is in peril from internal threats

ANS: 1 This theory speaks of anxiety existing along a continuum, a feature that corresponds to the four stages of anxiety. Option 2 is an explanation based on behavioral theory. Option 3 is a biologic theory. Option 4 is an inaccurate statement derived from the psychodynamic model. 2. The nurse designing a teaching plan for family members of clients with agoraphobia should make it a priority to plan to: 1. Discuss the importance of supporting client independence 2. Advise family members to avoid discussing the client’s progress 3. Include signs and symptoms of impending relapse of the phobia 4. Teach strategies for promoting improved hygiene and grooming

ANS: 1 Clients with agoraphobia need positive reinforcement and support for becoming more independent relative to leaving the home unaccompanied. Families are apt to assume the roles of the compromised member and take on that member’s tasks, such as shopping. They must support the independence afforded by recovery. 2. There is no need to restrict discussion of progress; in fact, positive feedback is warranted. 3. The signs and symptoms of relapse are obvious, because the client becomes more reluctant to leave the home. 4. Hygiene and grooming deficits are not associated with agoraphobia. 3. A week ago an individual witnessed the explosion of a fuel tanker, after which a “ball of fire” came directly at her. She literally “ran for her life.” She now reports feeling numb and not being able to respond spontaneously to others. She feels estranged and detached from others. Whenever anyone mentions the experience, she responds, “I need to avoid thinking about it.” The nurse taking her history would assess that the client’s risk for developing posttraumatic stress syndrome is: 1. High to moderate 2. Moderate 3. Low to moderate 4. Nonexistent

ANS: 1 The client’s coping mechanisms are characterized by avoidance. These defenses are not conducive to resolution. Unless the experience can be detoxified and integrated, PTSD is likely to develop. 4. What is the significant advantage of planning to use the humanistic nursing model in providing care to clients with anxiety disorders? The nurse: 1. Remains detached and has less opportunity to become anxious 2. Is expected to be fully available and in relationship with the client 3. Uses techniques derived from classical and operant conditioning 4. Is primarily concerned with milieu management

ANS: 2 The humanistic nursing theory sees nursing as an interactive process occurring between two persons—one needing help and one willing to give help. The nurse is identified as being part of, rather than an observer of, the interactive helping process. *5. A client has been treated with medication and psychotherapy for generalized anxiety disorder. Discharge from treatment is being contemplated. To obtain an objective measure of treatment success, the nurse will: 1. Elicit informtion about client satisfaction with treatment 2. Ask the client whether he is experiencing anxiety at or below the mild level 3. Administer the Hamilton Anxiety Scale 4. Use the Yale-Brown Obsessive-Compulsive Scale

ANS: 3 A rating scale will give the most objective measure of the degree to which anxiety has been effectively treated. The Hamilton Anxiety Scale would be the more appropriate to use since the scale mentioned in option 4 is specific for OCD. Options 1 and 2 are more subjective in nature. 6. A client comes for treatment for persistent, severe anxiety. An appropriate nursing diagnosis to validate would be: 1. Disturbed sensory perception related to narrowed perceptual field 2. Risk for injury related to closed perception 3. Hopelessness related to total loss of control 4. Risk for other-directed violence related to combative behavior

ANS: 1 A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses.

7. The client was an awkward child who was ridiculed by his father for his inability to catch a ball. As an adult, the client developed panic attacks at the time his company established after-work team sporting activities. The advanced practice nurse determines that the client’s anxiety occurs in relation to: 1. A signal that predicts a feared event 2. His physiologic responses to sports 3. A genetic deficiency of neurotransmitters 4. An unresolved desire to be a baseball player

ANS: 1 This scenario illustrates the behavioral model, which attributes the etiology of anxiety disorders to an earlier traumatic experience. 2. The symptoms are not related to a physiologic cause. 3. There is no evidence of a deficiency. 4. This is not supported by data in the scenario. 8. The nurse is working with the family of a client with obsessive-compulsive disorder. Which of the following should the nurse incorporate in the teaching plan? 1. The thoughts, images, and impulses are voluntary. 2. The family should pay immediate attention to symptoms. 3. The thoughts, images, and impulses worsen with stress. 4. OCD is a chronic disorder and not responsive to treatment.

ANS: 3 Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the client’s life as much as possible. 1. The symptoms are not under the client’s voluntary control. 2. This is nontherapeutic because it contributes to secondary gain. 4. OCD responds well to medication and therapy. 9. Which question should the nurse ask to determine whether the client has been experiencing anxiety? 1. "Have you had more difficulty concentrating lately?" 2. "Have you been feeling sad and lonely?" 3. "Do you have a history of nerves?" 4. "Do you frequently feel angry and upset?"

ANS: 1 Concentration difficulties occur when moderate or greater levels of anxiety are present. Option 2 assesses mood. Option 3 is a misnomer and would not necessarily provide accurate data. Option 4 assesses aggressive or anger symptoms. 10. An advanced practice nurse has identified a nursing diagnosis of impaired social interaction for a client with obsessive-compulsive disorder. An appropriate outcome for this problem would be that the client will: 1. Convince peers to join in the performance of the rituals

2. Speak of the baselessness of her obsessions in group 3. Avoid obsessing while interacting with the nurse 4. Describe increasing control over intrusive thoughts

ANS: 4 It is desirable for the client to experience a sense of being able to control the obsessive thinking. 1. This would be inappropriate. 2. Clients with OCD often speak of their obsessions as being “silly and senseless,” so this outcome shows no progress. 3. This is too short-term to be of enduring value to the client. 11. An evening staff nurse was raped 6 months ago while walking to the train station. She immediately returned to work and did not focus on the incident. Recently, the nurse has been having nightmares and difficulty communicating with her boyfriend. An appropriate outcome for treatment is that the nurse will: 1. Develop improved coping skills 2. Participate in a zsupport group 3. Verbalize her anger toward her boyfriend 4. Learn how to protect herself from rape

ANS: 2 Participation in a support group is recommended for clients experiencing PTSD. 1. There is no evidence that the nurse has poor coping skills. 3. There is no evidence that the nurse is angry with her boyfriend. 4. This outcome implies that the nurse is, in part, responsible for the rape. 12. The nurse has been working with a client who experiences anxiety. The goal is that the client will identify early symptoms of anxiety. Which outcome would the nurse evaluate as indicative that the client is making progress toward this goal? The client: 1. Retrospectively connects stress situations and anxiety 2. Reports no symptoms of anxiety for 1 week 3. Practices relaxation techniques daily 4. Recognizes that others also experience anxiety

ANS: 1 This indicates growth in learning the precipitants of anxiety. Option 2 is not realistic. Option 3 is beneficial but not related to the goal. Option 4 reduces egocentricity but is not related to the goal. 13. Which strategy should the nurse incorporate in the nursing care plan for a client with generalized anxiety disorder? 1. Tell the client to calm down when anxiety is apparent 2. Encourage the client to discuss painful childhood issues 3. Teach the importance of limiting caffeine, nicotine, and CNS stimulants 4. Inform the client that he will need to remain calm if he wishes to attend group therapy

ANS: 3 CNS stimulants, including caffeine and nicotine, increase anxiety symptoms. Options 1 and 4 are nontherapeutic interventions. Option 2 is not a strategy to improve anxiety management. 14. The advanced practice nurse is planning to use systematic desensitization with a client who has agoraphobia. The initial step the nurse will plan is to: 1. Define the phobic stimulus 2. Define a hierarchy of symptoms 3. Expose the client to the stimulus 4. Incorporate relaxation teaching

ANS: 1 The phobic stimulus must be defined before beginning the systematic desensitization process. Options 2, 3, and 4 are follow-up steps in the process. 15. The nurse is working with a client who has been diagnosed as having PTSD related to a combat situation. An initial outcome for the client is that he will: 1. Verbalize feelings about the combat experience 2. Repress memories and feelings about the experience 3. Recognize that the symptoms are masking his fear 4. Leave the military because symptoms are war related

ANS: 1 Expressing feelings permits identification of feelings. This initial step makes it possible to devise effective ways to manage feelings more effectively. 2. This would be nontherapeutic. 3. The symptoms reflect unresolved feelings, not solely fear. 4. This will not help the disorder. 16. The nurse working with a client with an anxiety disorder should explain that the success of cognitive behavioral therapy is based on the client's understanding that: 1. Antecedents of anxiety are childhood traumas 2. Symptoms are related to delusional thoughts 3. The problems are all in the client’s mind 4. Symptoms are learned responses to thoughts

ANS: 4 Cognitive therapy helps clients identify target symptoms and change the cognitions associated with them. 1. This is a psychodynamic model explanation. 2. This is not useful, since anxiety disorders have no relationship to delusions. 3. This is not a useful construct. 17. The nurse working with a client who experiences chronic anxiety is teaching anxiety-reduction strategies. Which is the best direction for the nurse to give?

1. 2. 3. 4.

“Focus your mind on the anxiety-producing situation.” “Imagine yourself in a quiet, peaceful place.” “Focus your attention on the whole room.” “Think about being in a large crowd.”

ANS: 2 Visual imagery is the only anxiety-management strategy mentioned in these options. 18. Which verbal intervention would be preferable to use with a client who is experiencing severe to panic-level anxiety? 1. “I will stay with you and help you become calmer.” 2. “You must stop pacing and wringing your hands.” 3. “How can I help you get control of yourself?” 4. “Let’s talk about what was happening just before you got upset.”

ANS: 1 A client who is experiencing severe to panic-level anxiety requires brief, directive verbal interchanges aimed at increasing feelings of safety and security. 2. Although brief and directive, this communication does nothing to increase feelings of security. 3. Severely anxious clients are not able to evaluate their situation and give direction to the nurse. 4. Severely anxious clients are not able to relate antecedent events to increasing anxiety. 19. The nurse notes that a client being treated for an anxiety disorder is becoming more anxious as he sits in a congested, noisy room waiting for his turn to see the therapist. The nurse should intervene by: 1. Calling security guards to stand by in an area near the waiting room 2. Taking the client to an unoccupied interview room 3. Notifying the therapist of the need to see the client stat 4. Requesting prn anxiolytic medication for the client

ANS: 2 A congested, noisy environment is not conducive to maintenance of low anxiety. Moving the client to a less stimulating environment may be all that is needed for the client to lower his anxiety level. Each of the other options will be unnecessary if the nurse intervenes early. 20. The physician tells the nurse, “I’ll probably begin medication therapy for my client with panic disorder, so be prepared to implement a medication teaching plan.” For which medication group will the nurse plan teaching? 1. Tricyclic antidepressants 2. Monamine oxidase inhibitors 3. Selective serotonin reuptake inhibitors 4. Benzodiazepines

ANS: 3 SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. 1. These medications are effective but have more side effects than SSRIs. 2. These medications are effective but require knowledge of and compliance with a special diet. 4. These medications are effective but produce alterations in sensorium and other side effects. *21. A client relates the following history: the presence of intrusive thoughts that her hands are contaminated by illness-producing bacteria and the uncontrollable urge to scrub her hands and anything she has touched. The nurse will plan to access and modify the standard care plan for: 1. Generalized anxiety disorder 2. Panic disorder 3. Obsessive-compulsive disorder 4. Posttraumatic stress disorder

ANS: 3 These symptoms are consistent with DSM-IV-TR criteria for obsessive-compulsive disorder. This clinical picture is neither suggestive of nor consistent with DSM-IV-TR criteria for generalized anxiety disorder (option 1), panic disorder (option 2), or posttraumatic stress disorder (option 4). *22. A client comes to the ED for the fifth time in 2 weeks with severe physical and emotional symptoms: She is diaphoretic, her heart is racing (124 bpm), she states she cannot breathe, and she is experiencing chest pain. Her BP is 148/90, and she tells the nurse she is afraid she is going to die. On all five visits, no physical cause for the symptoms could be determined. The nurse analyzes the history and symptoms as being most consistent with the medical diagnosis: 1. Phobia 2. Panic disorder 3. Generalized anxiety disorder 4. Anxiety trait problem

ANS: 2 The symptoms are consistent with those of panic disorder. 1. There is no mention of an object of fear. 3. The symptoms are more acute than for generalized anxiety disorder. 4. Anxiety trait problem is not a medical diagnosis. 23. A client with OCD tells the nurse, “Thinking these thoughts and doing all my rituals is beyond being silly. I know others laugh behind my back. I sometimes think I can control things, but I always find I can’t. I don’t know if I can continue to live this way…being a burden on my family and being of no use to myself.” The reply that shows the best understanding of the client’s priority risk is:

1. 2. 3. 4.

“How are you sleeping?” “Are your rituals interfering with eating?” “Have you been thinking about suicide? “What makes you think others are laughing behind your back?

ANS: 3 Clients with anxiety disorders should always be assessed for the presence of depression and suicidal ideation, the priority risk to safety. This client has admitted feeling powerless to control her symptoms, being a burden, and being useless, in addition to wondering if she can continue to live the way she has been. There is ample reason for asking about suicidal ideation. Options 1 and 2 do not address the priority risk. Option 4 is not a therapeutic inquiry. 24. 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.” Staff should be alert for clients who demonstrate: 1. Exaggerated mood swings within short periods of time 2. Perceptual distortions including auditory hallucinations 3. Dissociative symptoms such as numbing, derealization, detachment 4. Multiple exaggerated somatic complaints without organic basis

ANS: 3 Acute stress reactions are characterized by indications of dissociation, such as those listed in option 3, and may develop within a short time after the incident. Options 1 and 2 suggest severe mental disorders, and option 4 suggests somatization disorder. **25. A nurse notes that a new client displays restlessness, hypervigilance, rapid pulse, dilated pupils, rapid shallow breathing, decreased attention, and an inability to reason effectively. The nurse should document the level of anxiety as: 1. Mild +1 2. Moderate +2 3. Severe +3 4. Panic +4

ANS: 3 The cognitive symptoms given in the scenario suggest severe anxiety. Options 1 and 2: In mild and moderate anxiety, thinking is not distorted. Option 4: In panic level anxiety, the client is even more disorganized. 26. A physician scolds a nurse. When a family member enters the client’s room, that nurse tells the person cruelly that they need to wait until visiting hours. The supervising nurse should discuss this incident with the nurse, using knowledge that the defense mechanism the nurse used was:

1. 2. 3. 4.

Displacement Projection Sublimation Suppression

ANS: 1 Displacement is transferring a response or feeling toward one person onto another less threatening person, so option 1 is correct. 2. Projection is attributing strong faults to another and is not displayed in this scenario. 3. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors. 4. This is incorrect because suppression is intentionally avoiding thinking about problem areas. 27. The nurse assesses a young teen client. The client states, “I don’t care what you say. I want to be just like Mike, the leader of our gang.” The nurse understands the defense mechanism being used is: 1. Denial 2. Humor 3. Splitting 4. Identification

ANS: 4 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. 28. A young, married female client is attracted to a male nurse. The client falsely accuses the male nurse of sexual harassment. The nursing supervisor recognizes the defense mechanism of: 1. Projection 2. Splitting 3. Suppression 4. Displacement

ANS: 1 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. 29. A woman comes into the ED staggering and under the influence of alcohol. The staff members recognize her as having a chronic drinking problem. She declares, “I do not have a problem. I can stop drinking any day.” The defense mechanism displayed is: 1. Humor

2. Denial 3. Devaluation 4. Sublimation

ANS: 2 The woman is refusing to acknowledge ...