exam 1 chapter 11

A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to:

A patient approaches the nurse and impatiently blurts out, “You’ve got to help me! Something terrible is happening. My heart is pounding.” The nurse responds, “It’s almost time for visiting hours. Let’s get your hair combed.” Which approach has the nurse used?

A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be:

A patient with a high level of motor activity runs from chair to chair and cries, “They’re coming! They’re coming!” The patient does not follow instructions or respond to verbal interventions from staff. The initial nursing intervention of highest priority is to:

A patient with a high level of motor activity runs from chair to chair and cries, “They’re coming! They’re coming!” The patient is unable to follow instructions or respond to verbal interventions from staff. Which nursing diagnosis has the highest priority?

A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, “I’ve been working on other things.” When asked 4 hours later, the worker says, “Someone else was using the copier, so I couldn’t finish it.” The worker’s behavior demonstrates:

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

A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What are they going to do?” Assessment findings include a tremulous voice, respirations 28 breaths per minute, and pulse rate 110 beats per minute. What is the patient’s level of anxiety?

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

A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention?

Which assessment question would be most appropriate for the nurse to ask a patient who has possible generalized anxiety disorder (GAD)?

A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient?

A person has minor physical injuries after an automobile 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 this person’s level of anxiety?

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 defense mechanism is evident?

A patient tells a nurse, “My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can’t find a single flaw.” This patient is demonstrating:

A patient experiences an episode of severe anxiety. Of these medications in the patient’s medical record, which is most appropriate to administer as an as-needed (PRN) anxiolytic medication?

Two staff nurses applied for promotion to nurse manager. Initially, the nurse not promoted had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse’s response?

A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of:

A person who is speaking about a contender for a significant other’s affection says in a gushy, syrupy voice, “What a lovely person. That’s someone I simply adore.” The individual is demonstrating:

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

A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nurse can correctly assess the student’s experience as:

A student says, “Before taking a test, I feel a heightened sense of awareness and restlessness.” The nursing intervention most suitable for assisting the student is to:

If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person?

A patient experiencing severe anxiety suddenly begins running and shouting, “I’m going to explode!” The nurse should:

A person who has been unable to leave home for more than a week because of severe anxiety says, “I know it does not make sense, but I just can’t bring myself to leave my apartment alone.” Which nursing intervention is appropriate?

Which comment by a person experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder?

Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to:

Which statement is mostly likely to be made by a patient diagnosed with agoraphobia?

A patient has the nursing diagnosis Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis?

A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies?

For a patient experiencing panic, which nursing intervention should be implemented first?

Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient:

A patient tells the nurse, “I don’t go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at.” The nurse assesses this behavior as consistent with:

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 that a house fire is not likely. This counseling demonstrates the principles of:

A patient has a fear of public speaking. The nurse should be aware that social anxiety disorders (social phobias) are often treated with which type of medication?

A patient tells the nurse, “I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?” The nurse’s reply should be based on the knowledge that buspirone: