Anxiety, Obsessive-Compulsive, and Related Disorders

Question 1

The nurse assesses an adult who is socially withdrawn and hoards.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
b.Situational low self-esteem
c.Chronic low self-esteem
d.Disturbed body image
e.Risk for injury

Answer 1

ANS: A, C, E
Shame regarding the appearance of one’s home is associated with hoarding. The behaviour 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.

Question 2

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

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?”

Answer 2

ANS: B, D, E
The correct questions refer to obsessive thinking and compulsive behaviours. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected post-traumatic stress disorder or with suspected social phobia. See relationship to audience response question.

Question 3

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.

Answer 3

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 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.

Question 4

For a patient experiencing panic, which nursing intervention should be implemented first?
a.Teach relaxation techniques.
b.Administer an anxiolytic medication.
c.Prepare to implement physical controls.
d.Provide calm, brief, directive communication.

Answer 4

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.

Question 5

A patient performs ritualistic handwashing. Which action should the nurse implement to help the patient develop more effective coping?
a.Displacement
b.Reflection
c.Systematic desensitization
d.Reaction formation

Answer 5

ANS: B
Systematic desensitization will assist the patient to develop more effective coping. The patient is gradually introduced to a feared object or experience through a series of steps, from the least frightening to the most frightening (graduated exposure). The patient is taught to use a relaxation technique at each step when anxiety becomes overwhelming. Displacement, reflection and reaction formation are defence mechanisms, not a form of behavioural therapy

Question 6

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?
a.Feelings of responsibility for the health of family members
b.Approval-seeking behaviour from friends and family
c.Persistent thoughts about bacteria, germs, and dirt
d.Needs to avoid interactions with others

Answer 6

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 behaviour.

Question 7

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?
a.“I’m sure I will get over not wanting to leave home soon. It takes time.”
b.“Being afraid to go out seems ridiculous, but I can’t go out the door.”
c.“My family says they like it now that I stay home most of the time.”
d.“When I have a good incentive to go out, I can do it.”

Answer 7

ANS: B
Individuals who are agoraphobic generally acknowledge that the behaviour 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 behaviour. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

Question 8

When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to do which of the following?
a.Report drowsiness
b.Eat a tyramine-free diet
c.Avoid alcoholic beverages
d.Adjust dose and frequency based on anxiety level

Answer 8

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.

Question 9

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.”
b.“My legs often feel weak and spastic.”
c.I’m embarrassed to go out in public.”
d.“I keep reliving a car accident.”

Answer 9

ANS: A
Recurring doubt (obsessive thinking) and the need to check (compulsive behaviour) suggest obsessive-compulsive disorder. The repetitive behaviour 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 post-traumatic stress disorder.

Question 10

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?
a.Help the person use online video calls to provide interaction with others.
b.Advise the person to accept the situation and use a companion.
c.Ask the person to explain why the fear is so disabling.
d.Teach the person to use positive self-talk techniques.

Answer 10

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.

Question 11

A patient experiencing panic suddenly began running and shouting, “I’m going to explode!” Select the nurse’s best action.
a.Ask, “I’m not sure what you mean. Give me an example.”
b.Capture the patient in a basket-hold to increase feelings of control.
c.Tell the patient, “Stop running and take a deep breath. I will help you.”
d.Assemble several staff members and say, “We will take you to seclusion to help you regain control.”

Answer 11

ANS: C
Safety needs of the patient and other patients are a priority. Comments to the patient should be simple and 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.

Question 12

A cruel and abusive person often uses rationalization to explain the behaviour. Which comment demonstrates use of this defence mechanism?
a.I don’t know why I do mean things.”
b.“I have always had poor impulse control.”
c.That person should not have provoked me.”
d.“I’m really a coward who is afraid of being hurt.”

Answer 12

ANS: C
Rationalization consists of justifying one’s unacceptable behaviour 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 behaviour.

Question 13

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.
b.Advise the student to discuss this experience with a health care provider.
c.Encourage the student to begin antioxidant vitamin supplements.
d.Listen attentively, using silence in a therapeutic way.

Answer 13

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.

Question 14

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 which of the following?
a.Culturally influenced
b.Displacement
c.Trait anxiety
d.Mild anxiety

Answer 14

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. See relationship to audience response question.

Question 15

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defence mechanism is evident?
a.Rationalization
b.Compensation
c.Introjection
d.Regression

Answer 15

ANS: A
Rationalization involves unconsciously making excuses for one’s behaviour, inadequacies, or feelings. Regression involves the unconscious use of a behaviour 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.

Question 16

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 which of the following?
a.Reaction formation
b.Repression
c.Projection
d.Denial

Answer 16

ANS: A
Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behaviour. 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 behaviour by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

Question 17

A person who feels unattractive repeatedly says, “Although I’m not beautiful, I am smart.” This is an example of which of the following?
a.Repression
b.Devaluation
c.Identification
d.Compensation

Answer 17

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 behaviours of another. Devaluation occurs when the individual attributes negative qualities to self or others.

Question 18

Two staff nurses applied for promotion to nurse manager. The day of the job interviews, one nurse was told by her boyfriend that he wanted to end the relationship. Although visibly upset, the nurse does not think about what her boyfriend has said and prepares for the interview. Which term best describes the nurse’s response?
a.Altruism
b.Suppression
c.Intellectualization
d.Reaction formation

Answer 18

ANS: B
Suppression is the conscious denial of a disturbing situation or feeling. There is no evidence of altruism. 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 behaviours are controlled and kept out of awareness by developing the opposite behaviour or emotion.

Question 19

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?
a.Buspirone (Bustab)
b.Lorazepam (Ativan)
c.Phenelzine sulfate (Nardil)
d.Tranylcypromine sulfate (Parnate)

Answer 19

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. Phenelzine and tranylcypromine are monoamine oxidase inhibitors.

Question 20

15. A patient tells a nurse, “I was not able to write my final exam as I had a pounding headache and I was not able to read.” This patient is demonstrating which of the following?
    a.Denial
    b.Projection
    c.Compensation
    d.Conversion

Answer 20

ANS: D
Conversion is the unconscious transformation of anxiety into a physical symptom with no organic cause. Often, the symptom functions to gain attention or provide an excuse. Compensation would result in the patient unconsciously attempting to make up for a perceived weakness by emphasizing a strong point. 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 behaviour.

Question 21

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 defence mechanism is evident?
a.Introjection
b.Conversion
c.Projection
d.Splitting

Answer 21

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.

Question 22

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?
a.Mild
b.Moderate
c.Severe
d.Panic

Answer 22

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 behaviour and may lose touch with reality.

Question 23

A patient in the emergency department shows disorganized behaviour and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient?
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

Answer 23

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 overstimulating and unsafe.

Question 24

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?
    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.

Answer 24

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.

Question 25

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

Answer 25

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.

Question 26

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?
a.Mild
b.Moderate
c.Severe
d.Panic

Answer 26

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 behaviour.

Question 27

Which is an intermediate indicator of the nursing outcome of anxiety self-control?
a.Maintains adequate sleep
b.Monitors intensity of anxiety
c.Controls anxiety response
d.Uses relaxation techniques to lower anxiety

Answer 27

ANS: C
Intermediate indicators of the nursing outcome anxiety self-control are controls anxiety response and maintains role performance. Maintains adequate sleep, monitors intensity of anxiety and uses relaxation techniques to lower anxiety are short term indicators of the outcomes of anxiety self-control.

Question 28

A patient experiencing moderate anxiety says, “I feel undone.” An appropriate response for the nurse would be which of the following?
a.“What would you like me to do to help you?”
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.”

Answer 28

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.

Question 29

A patient fearfully runs from chair to chair, crying, “They’re coming! They’re coming!” The patient does not follow the staff’s directions or respond to verbal interventions. The initial nursing intervention of highest priority is to do which of the following?
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

Answer 29

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.

Question 30

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 counselling demonstrates principles of which of the following?
a.Flooding
b.Desensitization
c.Relaxation technique
d.Cognitive restructuring

Answer 30

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.