b. “Why do you suppose you are feeling anxious?” c. “I’m not sure I understand. Give me an example.” d. “You must get your feelings under control before we can continue.” ANS: C
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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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 15-39, 40, 83 (Table 15-9) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
4. A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The
_a
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patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to a. provide for the patient’s safety. b. encourage clarification of feelings. c. respect the patient’s personal space. d. offer an outlet for the patient’s energy. ANS: A
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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.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 15-18, 40, 72 (Table 15-4) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment 5. A patient fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The
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patient does not follow the staff’s directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Fear b. Risk for injury c. Self-care deficit d. Disturbed thought processes 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.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 15-40, 81 (Table 15-8), 85 (Table 15-10) TOP: Nursing Process: Diagnosis/Analysis
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