Chapter 15 Flashcards
A nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first?
a. Verify the client’s learning style.
b. Lower the client’s current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the client uses defense mechanisms.
b. Lower the client’s current anxiety.
A woman is 5’7”, 160 lbs. and wears a size 8 shoe. She says, “My feet are huge. I’ve asked three orthopedists to surgically reduce my feet.” This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely?
a. Social anxiety disorder
b. Body dysmorphic disorder
c. Separation anxiety disorder
d. Obsessive-compulsive disorder due to a medical condition
b. Body dysmorphic disorder
A client experiencing moderate anxiety says, “I feel undone.” What would be the appropriate response by the nurse?
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.”
c. “I’m not sure I understand. Give me an example.”
A client fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The client does not follow the staff’s directions or respond to verbal interventions. What is the initial nursing intervention of highest priority?
a. providing for the client’s safety.
b. encouraging clarification of feelings.
c. respecting the client’s personal space.
d. offering an outlet for the client’s energy
a. providing for the client’s safety.
A client fearfully runs from chair to chair crying, “They’re coming! They’re coming!” The client 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
b. Risk for injury
A client checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and client explore the likelihood of an actual fire. The client states this event is not likely. This counseling demonstrates what appropriate principle of therapy?
a. flooding.
b. desensitization.
c. relaxation technique.
d. cognitive restructuring.
d. cognitive restructuring.
A client undergoing diagnostic tests says, “Nothing is wrong with me except a stubborn chest cold.” The spouse reports the client smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the client using?
a. Displacement
b. Regression
c. Projection
d. Denial
d. Denial
A client with an abdominal mass is scheduled for a biopsy. The client 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 client’s level of anxiety?
a. Mild
b. Moderate
c. Severe
d. Panic
b. Moderate
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.
A client preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?
a. Reassure the client that all nurses are skilled in providing postoperative care.
b. Present the information again in a calm manner using simple language.
c. Tell the client that staff is prepared to promote recovery.
d. Encourage the client to express feelings to family.
b. Present the information again in a calm manner using simple language.
A client is experiencing moderate anxiety. The nurse encourages the client to talk about feelings and concerns. What is the rationale for this intervention?
a. Offering hope allays and defuses the client’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 clients to explore alternatives increases the sense of control and lessens anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving begin.
A nurse assesses a client with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask?
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?”
d. “Do you find it difficult to control your worrying?”
A client in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the client?
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
a. An interview room furnished with a desk and two chairs
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?
a. Mild
b. Moderate
c. Severe
d. Panic
c. Severe
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?
a. Introjection
b. Conversion
c. Projection
d. Splitting
c. Projection
A client 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 client is demonstrating
a. denial.
b. projection.
c. rationalization.
d. compensation.
c. rationalization.
