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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

MSC: Client Needs: Safe, Effective Care Environment

6. 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 this event is not likely. This counseling demonstrates principles of a. flooding. b. desensitization. c. relaxation technique. 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-51, 52, 72 (Table 15-4) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. Displacement b. Regression c. Projection d. Denial

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

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Mild b. Moderate c. Severe d. Panic

8. A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse’s comments and asks, “What do you mean? What are they going to do?” Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient’s level of anxiety?

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-4, 5, 64 (Table 15-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Physiological Integrity a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.

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

ANS: B

Giving information in a calm, simple manner will help the patient grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the patient’s attention.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 15-39, 40 (Table 15-9) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. Offering hope allays and defuses the patient’s anxiety. b. Concerns stated aloud become less overwhelming and help problem solving begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

10. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention?

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-39, 40, 83 (Table 15-9) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity a. “Have you been a victim of a crime or seen someone badly injured or killed?” b. “Do you feel especially uncomfortable in social situations involving people?” c. “Do you repeatedly do certain things over and over again?” d. “Do you find it difficult to control your worrying?”

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?

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 15-22, 23, 44 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. An interview room furnished with a desk and two chairs b. A small, empty storage room with no windows or furniture c. A room with an examining table, instrument cabinets, desk, and chair d. The nurse’s office, furnished with chairs, files, magazines, and bookcases

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 patient?

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 15-6 (Case Study and Nursing Care Plan), 64 (Table 15-1), 72 (Table 15-4), 85 (Table 15-10) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment a. Mild b. Moderate c. Severe d. Panic

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?

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 reality.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-5, 64 (Table 15-1) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Introjection b. Conversion c. Projection d. Splitting

14. 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?

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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 demonstrating a. denial. b. projection. c. rationalization. d. compensation.

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. buspirone b. lorazepam c. amitriptyline d. desipramine

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?

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.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 15-45, 46, 88 (Table 15-11) TOP: Nursing Process: Implementation

MSC: Client Needs: Physiological Integrity a. Altruism b. Suppression c. Intellectualization d. Reaction formation

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?

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

18. A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of a. repression. b. devaluation. c. identification. d. 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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 demonstrating a. reaction formation. b. repression. c. projection. d. denial.

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 awareness.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity a. Rationalization b. Compensation c. Introjection d. Regression

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

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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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 as a. culturally influenced. b. displacement. c. trait anxiety. d. 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.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 15-4, 64 (Table 15-1)

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment