ch 32 Flashcards
A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization
b. Ineffective coping related to hospitalization
c. Denial related to hospitalization
d. High risk for insomnia related to hospitalization
ANS: A
The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient’s data do not support defensive coping, ineffective denial, or risk-prone health behavior as problems for this patient.
A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time?
a. Massage
b. Meditation
c. Guided imagery
d. Relaxation breathing
ANS: D
Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.
The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate?
a. “How do you feel about what happened to you as a child?”
b. “How do you feel about what is going on right now?”
c. “Remember a time when you were calm.”
d. “Tap your hands until the feeling goes away.”
ANS: B
Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.
The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic?
a. Encourage the patient to begin dating again, perhaps with members of her church.
b. Discuss how divorce support groups could increase coping and social support.
c. Note that being so particular about potential friends reduces social contact.
d. Discuss using the Internet as a way to find supportive others with similar values.
ANS: B
Use of support groups is a method whereby the individual uses inter-related coping strategies in the presence of a stressor. The nurse should focus on providing the patient with coping strategies aimed at decreasing stress. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.
A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting?
a. “What kinds of things do you do to reduce or cope with your stress?”
b. “Tell me about your family history—do any relatives have problems with stress?”
c. “Tell me about exercise—how far do you typically run when you go jogging?”
d. “Stress can interfere with sleep. How much did you sleep last night?”
ANS: A
The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. These data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).
A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective?
a. The medication will become effective immediately.
b. The medication may take up to 12 weeks to become effective.
c. The medication may take up to 6 weeks to become effective.
d. The medication may take up to 4 weeks to become effective.
ANS: B
Efficacy may take at least 8–12 weeks. The other options are not realistic.
The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.)
a. Cancer
b. Pancreatitis
c. Hypothyroidism d. Dysrhythmias
e. Encephalitis
f. Hyperthyroidism
ANS: A,C,D,E,F
Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.
The nurse is reviewing the medication profile of a patient admitted with an anxiety disorder. Which medications should alert the nurse to a potential interaction? (Select all that apply.)
a. St. John’s Wort
b. Kava kava
c. Aspirin 81 mg
d. Valerian root
e. Multi-vitamin
ANS: A, B, D
Although supplements are available to purchase that “treat” anxiety, they are not under control of the Food and Drug Administration (FDA), so the nurse should obtain additional information relative to the use of any supplements that the patient is taking. Dosage of aspirin relates to a cardiac dose and a multi-vitamin would not pose a problem.
