chapter 18 and 19

Question 1

A client living in a beachfront community is seeking help with an extreme fear of bridges, which is interfering with daily functioning. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this treatment should the nurse provide?

1. “Using your imagination, we will attempt to achieve a state of relaxation.”
2. “Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response.”
3. “Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety.”
4. “In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.”

Answer 1

ANS: 3
Rationale: The nurse should explain to the client that when participating in systematic desensitization he or she will go through a series of increasingly anxiety-provoking steps that will gradually increase tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

Question 2

A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

1. The client will refrain from ritualistic behaviors during daylight hours.
2. The client will wake early enough to complete rituals prior to breakfast.
3. The client will participate in three unit activities by day three.
4. The client will substitute a productive activity for rituals by day one.

Answer 2

ANS: 2
Rationale: An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and begin to gradually limit the time allowed for rituals.

Question 3

A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions?

1. “I will need scheduled blood work in order to monitor for toxic levels of this drug.”
2. “I won’t stop taking this medication abruptly because there could be serious complications.”
3. “I will not drink alcohol while taking this medication.”
4. “I won’t take extra doses of this drug because I can become addicted.”

Answer 3

ANS: 1
Rationale: The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. This intervention is used when taking lithium (Eskalith) for the treatment of bipolar disorder. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol

Question 4

A college student is unable to take a final exam owing to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client?
A. Non-adherence R/T test taking
B. Ineffective role performance R/T helplessness
C. Altered coping R/T anxiety
D. Powerlessness R/T fear

Answer 4

ANS: C
Rationale: The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that will improve the client’s healthy coping skills and reduce anxiety.

Question 5

A client is experiencing a severe panic attack. Which nursing intervention would meet this client’s physiological need?

1. Teach deep breathing relaxation exercises.
2. Place the client in a Trendelenburg position.
3. Have the client breathe into a paper bag.
4. Administer the ordered prn buspirone (BuSpar).

Answer 5

ANS: 3
Rationale: The nurse can meet this client’s physiological need by having the client breathe into a paper bag. Hyperventilation may occur during periods of extreme anxiety. Hyperventilation causes the amount of carbon dioxide (CO2) in the blood to decrease, possibly resulting in lightheadedness, rapid heart rate, shortness of breath, numbness or tingling in the hands or feet, and syncope. If hyperventilation occurs, assist the client to breathe into a small paper bag held over the mouth and nose. Six to twelve natural breaths should be taken, alternating with short periods of diaphragmatic breathing.

Question 6

A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

1. Sublimation
2. Dissociation
3. Rationalization
4. Intellectualization

Answer 6

ANS: 4
Rationale: The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual process of logic, reasoning, and analysis.

Question 7

A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client’s problem?

1. Distract the client with other activities whenever ritual behaviors begin.
2. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
3. Lock the room to discourage ritualistic behavior.
4. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

Answer 7

ANS: 4
Rationale: The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to control interrupting anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client’s room are not appropriate interventions, because they do not help the client gain insight.

Question 8

A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor response is most accurate?

1. High doses of tricyclic medications will be required for effective treatment of OCD.
2. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD.
3. The dose of Luvox is low because of the side effect of daytime drowsiness.
4. The dose of this selective serotonin reuptake inhibitor (SSRI) is outside the therapeutic range and needs to be questioned.

Answer 8

ANS: 2
Rationale: The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness

Question 9

. A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order?
A. History of alcohol use disorder
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension

Answer 9

ANS: A
Rationale: The nurse should question a prescription of alprazolam for acute anxiety if the client has a history of alcohol use disorder. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance use disorder may be more likely to abuse other addictive substances.

Question 10

During her aunt’s wake, a four-year-old child runs up to the casket before a mother can stop her. An appointment is made with a nurse practitioner when the child starts twisting and pulling out hair. Which nursing diagnosis should the nurse practitioner assign to this child?
A. Complicated grieving
B. Altered family processes
C. Ineffective coping
D. Body image disturbance

Answer 10

ANS: C
Rationale: Ineffective coping is defined as an inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. This child is coping with the anxiety generated by viewing her deceased aunt by pulling out hair. If this behavior continues, a diagnosis of hair-pulling disorder, or trichotillomania, may be assigned.

Question 11

serotonin and GABA is decreased, norepinephrine is increased, in in which disorder

Answer 11

anxiety disorder

Question 12

Serotonin, clomipramine (Anafranil) SSRIs med

Answer 12

OCD

Question 13

behavior therapy is used to treat which disorder?
covert desensitization and HRT
positive and negative reinforcements

Answer 13

trichotillomania

Question 14

systematic desensitization and implosion therapy (flooding) behavior therapy is used to treat?

Answer 14

OCD

Question 15

Panic and GAD meds that can e used as need bases

must be tapered off and may be abused

Answer 15

Anxiolytics
Benzodiazepines
Alprazolam, lorazepam, clonazepam
Meds are addictive and need weaned off

Question 16

Panic disorder med

Answer 16

Prozac

Question 17

acute anxiety med

Answer 17

propranolol

Question 18

adjustment disorder with anxiety symptoms

Answer 18

nervousness, worry, jitteriness

Question 19

social anxiety and agoraphobia meds

Answer 19

SSRIs
paroxetine
sertraline

Question 20

A nursing instructor is teaching about trauma and stressor-related disorders. Which student statement indicates that further instruction is needed?

1. “The trauma that women experience is more likely to be sexual assault and child sexual abuse.”
2. “The trauma that men experience is more likely to be accidents, physical assaults, combat, or viewing death or injury.”
3. “After exposure to a traumatic event, only 10 percent of victims develop post-traumatic stress disorder (PTSD).”
4. “Research shows that PTSD is more common in men than in women.”

Answer 20

ANS: 4
Rationale: Research shows that PTSD is more common in women than in men. This student statement indicates a need for further instruction.

Question 21

Which factors differentiate the diagnosis of PTSD from the diagnosis of adjustment disorder (AD)?

1. PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events.
2. AD results from exposure to an extreme traumatic event, whereas PTSD results from exposure to “normal” daily events.
3. Depressive symptoms occur in PTSD and not in AD.
4. Depressive symptoms occur in AD and not in PTSD.

Answer 21

ANS: 1
Rationale: PTSD results from exposure to an extreme traumatic event, whereas AD results from exposure to “normal” daily events, such as divorce, failure, or rejection. Depressive symptoms can occur in both PTSD and AD.

Question 22

Which client would a nurse recognize as being at highest risk for the development of an AD?

1. A young married woman
2. An elderly unmarried man
3. A young unmarried woman
4. A young unmarried man

Answer 22

ANS: 3
Rationale: Adjustment disorders are more common in women, unmarried persons, and younger people. Although more common in the young, it can occur at any age.

Question 23

A nursing instructor is explaining the etiology of trauma-related disorders from a learning theory perspective. Which student statement indicates that learning has occurred?

1. “How clients perceive events and view the world affect their response to trauma.”
2. “The psychic numbing in PTSD is a result of negative reinforcement.”
3. “The individual becomes addicted to the trauma owing to an endogenous opioid response.”
4. “Believing that the world is meaningful and controllable can protect an individual from PTSD.”

Answer 23

ANS: 2
Rationale: Learning theorists view negative reinforcement as behavior that leads to a reduction in an aversive experience, thereby reinforcing and resulting in repetition of the behavior. Psychic numbing decreases or protects an individual from emotional pain and, therefore, the learned response is the repetition of this behavior.

Question 24

As the sole survivor of a roadside bombing, a veteran is experiencing extreme guilt. Which nursing diagnosis would address this client’s symptom?

1. Anxiety
2. Altered thought processes
3. Complicated grieving
4. Altered sensory perception

Answer 24

ANS: 3
Rationale: The client’s survivor guilt is disrupting the normal process of grieving. Although the client may also experience anxiety, the symptom presented in the question is extreme guilt. There is no evidence presented in the question to indicate altered thought or altered sensory perception.

Question 25

A client has been assigned a nursing diagnosis of complicated grieving related to the death of multiple family members in a motor vehicle accident. Which intervention should the nurse initially employ?

1. Encourage the journaling of feelings.
2. Assess for the stage of grief in which the client is fixed.
3. Provide community resources to address the client’s concerns.
4. Encourage attending a grief therapy group.

Answer 25

ANS: 2
Rationale: Prior to implementing all other nursing interventions presented, the nurse must assess the stage of grief in which the client is fixed. Appropriate nursing interventions are always based on accurate assessments.

Question 26

Which clinical presentation is associated with the most commonly diagnosed adjustment disorder (AD)?

1. Anxiety, feelings of hopelessness, and worry
2. Truancy, vandalism, and fighting
3. Nervousness, worry, and jitteriness
4. Depressed mood, tearfulness, and hopelessness

Answer 26

ANS: 4
Rationale: AD with depressed mood is the most commonly diagnosed adjustment disorder. The clinical presentation is one of predominant mood disturbance, although less pronounced than that of major depression. The symptoms, such as depressed mood, tearfulness, and feelings of hopelessness, exceed what is an expected or normative response to an identified stressor.

Question 27

Both situational and intrapersonal factors most likely contribute to an individual’s stress response. Which factor would a nurse categorize as intrapersonal?

1. Occupational opportunities
2. Economic conditions
3. Degree of flexibility
4. Availability of social supports

Answer 27

ANS: 3
Rationale: Intrapersonal factors that might influence an individual’s ability to adjust to a painful life change include social skills, coping strategies, the presence of psychiatric illness, degree of flexibility, and level of intelligence.

Question 28

A client diagnosed with AD has been assigned the nursing diagnosis of anxiety R/T divorce. Which correctly written outcome addresses this client’s problem?

1. Rates anxiety as 4 out of 10 by discharge.
2. States anxiety level has decreased by day one.
3. Accomplishes activities of daily living independently.
4. Demonstrates ability for adequate social functioning by day three.

Answer 28

ANS: 1
Rationale: An outcome statement must be client-centered, specific, measurable, and contain a time frame, so that it can be evaluated effectively. A “decrease” in anxiety is vague rather than specific, and expecting an anxiety decrease by day one may also be unrealistic. Accomplishing activities of daily living independently and demonstrating the ability for adequate social functioning do not address the anxiety nursing diagnosis.

Question 29

Eye movement desensitization and reprocessing (EMDR) has been empirically validated for which disorder?

1. Adjustment disorder
2. Generalized anxiety disorder
3. Panic disorder
4. Post-traumatic stress disorder

Answer 29

ANS: 4
Rationale: EMDR has been used for depression, adjustment disorder, phobias, addictions, generalized anxiety disorder, and panic disorder. However, at present, EMDR has only been empirically validated for trauma-related disorders such as PTSD and acute stress disorder.

Question 30

After a teaching session about grief, a client says to the nurse, “I seem to be stuck in the anger stage of grieving over the loss of my son.” How would the nurse assess this statement, and in what phase of the nursing process would this occur?

1. Assessment phase; nursing actions have been successful in achieving the objectives of care.
2. Evaluation phase; nursing actions have been successful in achieving the objectives of care.
3. Implementation phase; nursing actions have been successful in achieving the objectives of care.
4. Diagnosis phase; nursing actions have been successful in achieving the objectives of care.

Answer 30

ANS: 2
Rationale: In the evaluation phase of the nursing process, reassessment is conducted to determine if the nursing actions have been successful in achieving the objectives of care. The implementation of client teaching has enabled the client to verbalize an understanding of the grief process and his or her position in the process. Therefore, the nurse’s actions can be evaluated as successful.

Question 31

By which biological mechanism does EMDR achieve its therapeutic effect?

1. EMDR achieves its therapeutic effect, but the exact biological mechanism is unknown.
2. EMDR achieves its therapeutic effect by causing a decrease in imagery vividness.
3. EMDR achieves its therapeutic effect by causing an increase in memory access.
4. EMDR achieves its therapeutic effect by decreasing trauma associated anxiety.

Answer 31

ANS: 1
Rationale: Some studies have indicated that eye movements cause a decrease in imagery vividness and distress, as well as an increase in memory access. EMDR is thought to relieve anxiety associated with the traumatic event. However, the exact biological mechanisms by which EMDR achieves its therapeutic effects are unknown.

Question 32

A client receiving EMDR therapy says, “After only two sessions of my therapy, I am feeling great. Now I can stop and get on with my life.” Which of the following nursing responses is most appropriate?

1. “I am thrilled that you have responded so rapidly to EMDR.”
2. “To achieve lasting results, all eight phases of EMDR must be completed.”
3. “If I were you, I would complete the EMDR and comply with doctor’s orders.”
4. “How do you feel about continuing the therapy?”

Answer 32

ANS: 2
Rationale: Clients often feel relief quite rapidly with EMDR. However, to achieve lasting results, it is important that each of the eight phases be completed. The nurse’s most appropriate response should be to give information to correct the client’s misconceptions about the therapy. In answer 3 the nurse is subjectively giving advice rather than providing objective information.

Question 33

A nurse would recognize which treatment as most commonly used for AD and its appropriate rationale?

1. Psychotherapy; to examine the stressor and confront unresolved issues
2. Fluoxetine (Prozac); to stabilize mood and resolve symptoms
3. Eye movement desensitization therapy; to reprocess traumatic events
4. Lorazepam (Ativan); a first-line treatment to address symptoms of anxiety

Answer 33

ANS: 1
Rationale: Psychotherapy is the most common treatment used for AD. AD is not commonly treated with medications. Anxiolytic and antidepressant medications may be prescribed as adjuncts to psychotherapy but should not be given as the first line of treatment. Eye movement desensitization and reprocessing therapy is not used to treat adjustment disorders.

Question 34

A nurse has been caring for a client diagnosed with PTSD. Which realistic goal should be included in this client’s plan of care?

1. The client will have no flashbacks.
2. The client will be able to feel a full range of emotions by discharge.
3. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge.
4. The client will refrain from discussing the traumatic event.

Answer 34

ANS: 3
Rationale: Obtaining adequate sleep without zolpidem by discharge is a goal that should be included in the client’s plan of care. Having no flashbacks and experiencing a full range of emotions by discharge are unrealistic goals. Clients are encouraged, not discouraged, to discuss the traumatic event.

Question 35

A client diagnosed with PTSD is receiving paliperidone (Invega). Which symptoms should a nurse identify that would warrant the need for this medication?

1. Flat affect and anhedonia
2. Persistent anorexia and 10 lb weight loss in 3 weeks
3. Flashbacks of killing the enemy
4. Distant and guarded in relationships

Answer 35

ANS: 3
Rationale: The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone. Paliperidone is an antipsychotic medication that will address the symptoms of psychosis.