Chapter 15: Anxiety and Obsessive-Compulsive Disorders

1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first?
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b. Lower the patient's current anxiety.

ANS: B A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Use of defense mechanisms does not apply
2. A woman is 5'7", 160 lbs. and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
b. Body dysmorphic disorder

ANS: B Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual's symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.
c. "I'm not sure I understand. Give me an example."

ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.
a. provide for the patient's safety.

ANS: A Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient's energy can occur when the current panic level subsides. Respecting the patient's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.
b. Risk for injury

ANS: B A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority
d. cognitive restructuring.

ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response
d. Denial

ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another
b. Moderate

ANS: B Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior
b. Concerns stated aloud become less overwhelming and help problem solving begin.

ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.
11. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?d. "Do you find it difficult to control your worrying?" ANS: D. Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.12. A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patienta. An interview room furnished with a desk and two chairs ANS: A Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.13. A person has minor physical injuries after an auto 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 the person's level of anxiety?c. Severe ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality14. 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?c. Projection ANS: C Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.15. A patient tells a nurse, "My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had." This patient is demonstratingc. rationalization. ANS: C Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic?b. lorazepam ANS: B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially 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. Altruism ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse's reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.18. A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example ofd. compensation. ANS: D Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.19. A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstratinga. reaction formation. ANS: A. Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident?a. Rationalization ANS: A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.21. A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience asd. mild anxiety. ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.22. A student says, "Before taking a test, I feel very alert and a little restless." Which nursing intervention is most appropriate to assist the student?a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects. ANS: A Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.23. A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism?c. "That person should not have provoked me." ANS: C Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.24. A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best actionc. Tell the patient, "Stop running and take a deep breath. I will help you." ANS: C Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.25. 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?d. Teach the person to use positive self-talk techniques. ANS: D Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.26. A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder?a. "I check where my car keys are eight times." ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating "My legs feel weak most of the time" is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.27. When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching should include instructions toc. avoid alcoholic beverages. ANS: C Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.28. The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia?b. "Being afraid to go out seems ridiculous, but I can't go out the door." ANS: B Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house29. A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis?c. persistent thoughts about bacteria, germs, and dirt ANS: C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.30. A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping?b. Encourage the patient to participate in social activities. ANS: B Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom31. For a patient experiencing panic, which nursing intervention should be implemented first?d. Provide calm, brief, directive communication. ANS: D Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.32. A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? (Select all that apply)a. Use a calm manner and low voice. b. Maintain simplicity in the environment. e. Explain and reinforce reality to avoid distortions. The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns33. A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who begins a new prescription for lorazepam. What information should be included? (Select all that apply.)a. Caution in use of machinery c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.34. Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)b. "Are there others in your family who must do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of your awareness?" e. "Do you do certain things over and over again?" The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia35. The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)a. Ineffective home maintenance c. Chronic low self-esteem e. Risk for injury ANS: A, C, E Shame regarding the appearance of one's home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.