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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 symptom.

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

REF: Pages 15-38, 81 (Table 15-8) | Pages 15-41, 89 (Box 15-1)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Prepare to implement physical controls. d. Provide calm, brief, directive communication.

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

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.

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

REF: Pages 15-18, 72 (Table 15-4) TOP: Nursing Process: Implementation

MSC: Client Needs: Safe, Effective Care Environment

Multiple Response

1. 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.

c. Avoid repetition in what is said to the child.

d. Minimize opportunities for exercise and play.

e. Explain and reinforce reality to avoid distortions.

ANS: A, B, E

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 concerns.

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

REF: Pages 15-39, 40 (Table 15-9) | Pages 15-41, 89 (Box 15-1)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity a. Caution in use of machinery b. Foods allowed on a tyramine-free diet c. The importance of caffeine restriction d. Avoidance of alcohol and other sedatives e. Take the medication on an empty stomach

2. 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.)

ANS: A, C, D

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.

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

REF: Pages 15-88 (Table 15-11), 91 (Box 15-2)

MSC: Client Needs: Physiological Integrity

TOP: Nursing Process: Planning a. “Are there certain social situations that cause you to feel especially uncomfortable?” b. “Are there others in your family who must do things in a certain way to feel comfortable?” c. “Have you been a victim of a crime or seen someone badly injured or killed?” d. “Is it difficult to keep certain thoughts out of your awareness?” e. “Do you do certain things over and over again?”

3. Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? (Select all that apply.)

ANS: B, D, E

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 phobia.

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

REF: Pages 15-36, 37

MSC: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Ineffective home maintenance b. Situational low self-esteem c. Chronic low self-esteem d. Disturbed body image e. Risk for injury

4. The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)

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.

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

REF: Pages 15-29, 30, 38, 81 (Table 15-8)

TOP: Nursing Process: Analysis/Diagnosis