Ch 13 243 Nclex Flashcards Quizlet PDF

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Fridamaria43

Terms in this set (24) which level of anxiety

mild

helps the client forcus attention to learn,

-in mild anxiety sensory stimulation

problem solve, think, act,

increases and helps the person focus

feel, and protect himself?

attention to learn, solve problems, and think.

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-Moderate anxiety causes the person to have difficultry concentration independently but he or she can be redirected to the topic

which of the following is

the level of anxiety can be sustained

inconsistent with panic-

indefinitely

level anxiety -Panic-level anxiety cannot be sustained A. this level of anxiety

indefinitely. The nurse should remian with

can be sustained

the client until the panic recedes and

indefinitely

maintain a non stimulating environment.

B. the nurse needs to

The goal is to lower the client's anxiety to

maintain a non

mild or moderate before proceeding with

stimulating enviornment

anything else

C. the nurse should remain with the client until the panic recedes D. the goal is to lower the clients anxiety to mild or moderate beofre proceeding with anything else

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A client spends hours

compulsion

sacking and unstacking towels. She is repeatedly

-Compulsions are ritualistic or repetitive

checking to make sure

behaviors or mental acts that a person

that the towels are in

carries out continuously in an attempt to

order of color. This

neutralize anxiety.

behavior is identified as a -A phobia is an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning. -an obsession is a recurrent, persistent, intrusive, and unwanted thought, image, or impulse that causes marked anxiety and interference with interpersonal, social, or occupational function. -Derealization is sensing that things are not real

Panic disorder is treated

anti anxiety

with cognitive-behavioral techniques, deep

-Panic disorder is treated with cognitive-

breathing, and relaxation,

behavioral techniques, deep breathing and

in addition to which of

relaxation, and medication such as

the following?

benzodiazepines, SSRIs, tricyclics, and antihypertensives, such as Catapres and

A. antipsychotics

Inderal

B. CNS depressants C. antianxiety medications D. anticonvulsants

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post traumatic stress

flashbacks

disorder (PTSD) has been diagnosed in a sexually

-In PTSD, the person re-experiences all or

assaulted female client.

some of the traumatic event through

Which of the following

dreams or waking recollections and

manifestations is the most

responds defensively to these flashbacks.

consistent with PTSD? -Denial, humiliation, and self-blame are A. denial

normal feelings of rape

B. flashbacks C. self-blame D. humiliation

which of the following

touching the client in an attempt to

would not be an initial

comfort him

intervention for the client with acute anxiety?

-The nurse should evaluate carefully the use of touch b/c clients w/ high anxiety

A. use of open-ended

may interpret touch by a stranger as a

communication

threat and pull away abruptly. Use open-

techniques

ended questions, encourage the clients to

B. encouraging the client

verbalize feelings and concerns, and

to verbalize feeling and

maintaining a non stimulating environment.

concerns C. maintaining a nonstimulating environment D. touching the client in an attempt to comfort him

which of the following is

safety

the primary concern for a client with panic-level

-during panic-level anxiety, the person's

anxiety?

safety is the primary concern. He or she cannot perceive potential harm and may

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have no capacity for rational thought. Emotional needs, physiologic needs, and social support are important but not primary concern

when traveling alone and

Agoraphobia

away from home, a client experiences trembling

-occurs when the client travels away from

and palpitations, These

home and experiences anxiety, with

symptoms have impeded

symptoms such as palpitations and

the client from leaving

trembling

her home. The nurse would correctly note that these are symptoms of which type of phobia? A. OCD B. Agoraphobia C. Compulsion D. Obsession

A client is diagnosed with

giving the client time to perform rituals

with OCD. Which of the following should be

-the nurse should give the client time to

included in the plan of

perform rituals b/c this reduces anxiety.

care for this client?

The other options would increase the clients anxiety

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behavior D. Increasing environmental stimulation

which term describes

-depersonalization

feelings of being disconnected from

-Depersonalization describes feelings of

oneself as seen in a panic

being disconnected form oneself as seen

attack?

in a panic attack. -Derealization is sensing that things are not real -Automatisms are automatic, unconscious mannerisms -Agoraphobia is the fear of being outside

The nurse is assessing a

diarrhea

client suffering from stress and anxiety. The most common physiologic response to stress and anxiety is.. A skin rash B sedation C vertigo D. diarrhea

A client is admitted to an

repetitive thoughts and recurring,

inpatient psychiatric unit

irresistible impulses

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symptoms. OCD is

-OCD is associated with repetitive

associated with

thoughts and recurring, irresistible impulses,

A. physical signs and

-OCD is diagnoses only when these

symptoms with no

thought, images, and impulses consume

physiologic cause

the person or he or she is compelled to act

B. repetitive thoughts and

out the behaviors to a point at which they

recurring, irresistible

interfere with person, social, and

impulses

occupational function

C. inability to

-Physical signs and symptoms with no

concentrate

physiologic cause typify somatoform

D. apprehensive

disorder. -Apprehension and inability to concentrate characterize anxiety disorders

Nearly which percentage

25%

of adults is affected by anxiety disorders?

which of the following is

Tachycardia

a cardiovascular response of the

-tachycardia is a cardiovascular response

sympathetic nervous

of the sympathetic nervous system.

system?

Sympathetic cardiovascular reponses to stress include increased heart rate, cardiac

A. Tachycardia

contractility, and cardiac output; increased

B. Bradycardia

bp; and peripheral vasoconstriction

C. Bradypnea D. Hypotension

A client arrived on the

risk for injury

psychiatric unit exhibiting restlessness,

-this client is at increased risk for injury b/c

disorientation, incoherent

of severe hyperactivity, disorientation, and

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speech, agitation,

agitation. The nurses first action is to

purposeless physical

provide a safe environment and to ensure

activity, and suicidal

the clients privacy. the client's safety takes

ideations. Which of the

highest priority. The nurse should take

following is the priority

immediate action to protect the client from

nursing diagnosis for this

injury

client? A. Disturbed identity B. hopelessness C ineffective individual coping D. risk for injury

which of the following is

Buspirone (BuSpar)

classified as a nonbenzodiazepine?

-Ativan, Valium, and Librium are benzodiazepines.

A.Diazepam (Valium) B. Chlordiazepoxide (Librium) C. Lorazepam (Ativan) D. Buspirone (BuSpar)

which of the following

staying with the client and speaking in

would be an appropriate

short sentences

intervention of a client experiencing an anxiety

-Appropriate nursing interventions for an

attack?

anxiety attack include using short sentences, staying with the client,

A. turning on the lights

decreasing stimuli, remaining calm, and

and opening the

medicating as needed,

windows so that the client does not feel

-Leaving the client alone, turning in a

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B. Turning on stereo

stereo or lights, and opening windows may

music

increase the client's anxiety

C. staying with the client and speaking in short sentences D. Leaving the client alone

which of the following

rise slowly from a lying or sitting position

should be includes in a teaching plan for a client

-Clients takin a a benzodiazaepine should

prescribed a

rise slowly from a lying or sitting position.

benzodiazepine?

The client should drink adequate fluids, avoid caffeine, and not stop taking the

A. rise slowly form a lying

drug abruptly

or sitting position B. maintain a fluid restriction C. consume caffeine in moderation D. Stop taking drug if sedation develops

which of the following

touching the client in an attempt to

would not be included in

comfort him

the plan of care for a client diagnoses with

-the emergency nurse must establish

acute anxiety?

rapport and trust with the anxious client before using therapeutic touch. Touching

A. touching the client in

an anxious client may actually increase

an attempt to comfort

anxiety. Trust can be established by

him

approaching the client in a calm and

B. encouraging the client

confident manner; providing a place that is

to verbalize feeling and

quiet, safe, and private; and encouraging

concerns

the client to verbalize feeling and concerns

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C. Approaching the client in a calm, confident manner D. Providing the client with a safe, quiet, and private place

a client diagnosed with

increased anxiety

OCD is attempting to resist a compulsion.

-a client diagnosed with OCD who

Based on the finding the

attempts to resist the compulsion must be

nurse should assess the

evaluated for increased anxiety. A

client for...

compulsion is a repetitive, intentional behavior that the client performs in

A.excessive fear

response to a certain obsession; it is aimed

B. feeling of failure

at neutralizing of decreasing anxiety.

C. increased anxiety

Resisting the compulsion may increase the

D. depression

client's anxiety. Although a client with OCD may have feelings of failure, depression, and excessive fear, these are not responses to resisting the compulsion

which medication

-antidepressants

classification has been found to be effective in reducing or eliminating panic attacks?

which of the following is

hyperactive bowel sounds

a parasympathetic effect of anxiety?

The parasympathetic nervous system would produce increased GI motility,

-hyperactive bowel

resulting in hyperactive bowel sounds,

sounds

possibly leading to diarrhea. Sympathetic

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-decreased urine output

nervous system stimulation causes

-muscle tension

decreased urine output, constipation, and

-constipation

muscle tension

in which level of anxiety

Panic

does the clients cognitive process focus on on the

-panic anxiety reduces the perceptual field

persons defense

to focus on the self and the client cannot process any environmental stimuli. - In mild anxiety, sensory stimulation increasers and helps the person focus attention to learn, solve problems, and think. -Moderate anxiety causes the person to have difficulty concentrating independently, but he or she can be redirect to the topic -severe anxiety causes the person to have a reduced perceptual field and he or she cannot complete tasks

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