Chapter 18: Anxiety, Obsessive-Compulsive, and Related Disorders

Question 1

A nursing instructor is teaching about specific phobias. Which student statement indicates to the instructor that learning has occurred?

1. “These clients recognize their fear as excessive and frequently seek treatment.”
2. “These clients have a panic level of fear that is overwhelming and unreasonable.”
3. “These clients experience symptoms that mirror a cerebrovascular accident (CVA).”
4. “These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”

Answer 1

ANS: 2
Rationale: The nursing instructor should evaluate that learning has occurred when the student knows that clients with phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response. Even though the disorder is relatively common among the general population, people seldom seek treatment unless the phobia interferes with ability to function.

Question 2

Which nursing statement to a client about social anxiety disorder versus schizoid personality disorder (SPD) is most accurate?

1. “Clients diagnosed with social anxiety disorder can manage anxiety without medications, whereas clients diagnosed with SPD can only manage anxiety with medications.”
2. “Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social anxiety disorder are not.”
3. “Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.”
4. “Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social anxiety disorder tend to avoid interactions in all areas of life.”

Answer 2

ANS: 3
Rationale: Clients diagnosed with social anxiety disorder avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social anxiety disorder is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

Question 3

What symptoms should a nurse recognize that differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?

1. GAD is acute in nature, and panic disorder is chronic.
2. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
3. Hyperventilation is a common symptom in GAD and rare in panic disorder.
4. Depersonalization is commonly seen in panic disorder and absent in GAD.

Answer 3

ANS: 4
Rationale: The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

Question 4

Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)?

1. Long-term treatment with diazepam (Valium)
2. Acute symptom control with citalopram (Celexa)
3. Long-term treatment with buspirone (BuSpar)
4. Acute symptom control with ziprasidone (Geodon)

Answer 4

ANS: 3
Rationale: The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients diagnosed with GAD. Buspirone takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

Question 5

Which symptoms should a nurse recognize that differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder?

1. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not.
2. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not.
3. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions.
4. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.

Answer 5

ANS: 1
Rationale: A client diagnosed with OCD experiences both obsessions and compulsions. Clients with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, mental and interpersonal control, but do not experience obsessions and compulsions.

Question 6

6. A cab driver, stuck in traffic, becomes lightheaded, tremulous, diaphoretic, tachycardic and dyspneic. A workup in an emergency department reveals no pathology. Which medical diagnosis should a nurse suspect, and what nursing diagnosis should be the nurse’s first priority?
7. Generalized anxiety disorder and a nursing diagnosis of fear
8. Altered sensory perception and a nursing diagnosis of panic disorder
9. Pain disorder and a nursing diagnosis of altered role performance
10. Panic disorder and a nursing diagnosis of anxiety

Answer 6

ANS: 4
Rationale: The nurse should suspect that the client has exhibited signs and symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

Question 7

A client diagnosed with panic disorder states, “When an attack happens, I feel like I am going to die.” Which is the most appropriate nursing response?

1. “I know it’s frightening, but try to remind yourself that this will only last a short time.”
2. “Death from a panic attack happens so infrequently that there is no need to worry.”
3. “Most people who experience panic attacks have feelings of impending doom.”
4. “Tell me why you think you are going to die every time you have a panic attack.”

Answer 7

ANS: 1
Rationale: The most appropriate nursing response to the client’s concerns is to empathize with the client and provide encouragement that panic attacks only last a short period. Panic attacks usually last minutes but can, rarely, last hours. When the nurse states that “Most people who experience panic attacks…” the nurse depersonalizes and belittles the client’s feeling.

Question 8

A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred?

1. “Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder.”
2. “Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder.”
3. “Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks.”
4. “Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.”

Answer 8

ANS: 1
Rationale: The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine in which the major risk is physical dependence and tolerance, which may encourage abuse. It can be used on an as-needed basis to reduce anxiety and the related symptoms.

Question 9

A family member is seeking advice about an older parent who seems to worry unnecessarily about everything. The family member states, “Should I seek psychiatric help for my mother?” Which is an appropriate nursing response?

1. “My mother also worries unnecessarily. I think it is part of the aging process.”
2. “Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning.”
3. “From what you have told me, you should get her to a psychiatrist as soon as possible.”
4. “Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.”

Answer 9

ANS: 2
Rationale: The most appropriate response by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

Question 10

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 10

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 11

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 11

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 12

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 12

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 13

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 13

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 14

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 14

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 15

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 15

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 16

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 16

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 17

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 17

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 18

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 18

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 19

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 19

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 20

A nursing instructor is teaching about the symptoms of agoraphobia. Which student statement indicates that learning has occurred?

1. Onset of symptoms most commonly occurs in early adolescence and persists until midlife.
2. Onset of symptoms most commonly occurs in the 20s and 30s and persists for many years.
3. Onset of symptoms most commonly occurs in the 40s and 50s and persists until death.
4. Onset of symptoms most commonly occurs after the age of 60 and persists for at least 6 years.

Answer 20

ANS: 2
Rationale: The onset of the symptoms of agoraphobia most commonly occurs in the 20s and 30s and persists for many years.

Question 21

A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.)

1. Fatigue
2. Anorexia
3. Hyperventilation
4. Insomnia
5. Irritability

Answer 21

ANS: 1, 4, 5
Rationale: The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.

Question 22

A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. Which of the following commonly used behavioral therapies for phobias should the nurse explain to the client? (Select all that apply.)

1. Benzodiazepine therapy
2. Systematic desensitization
3. Imploding (flooding)
4. Assertiveness training
5. Aversion therapy

Answer 22

ANS: 2, 3
Rationale: The nurse should explain to the client that systematic desensitization and imploding are the most common behavioral therapies used for treating phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.

Question 23

A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client’s symptoms? (Select all that apply.)

1. Encourage the client to recognize the signs of escalating anxiety.
2. Encourage the client to avoid any situation that causes stress.
3. Encourage the client to employ newly learned relaxation techniques.
4. Encourage the client to cognitively reframe thoughts about situations that generate anxiety.
5. Encourage the client to avoid caffeinated products.

Answer 23

ANS: 1, 3, 4, 5
Rationale: Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention, because avoidance does not help the client overcome anxiety and because not all situations are easily avoidable.

Question 24

An attractive female client presents with high anxiety levels because of her belief that her facial features are large and grotesque. Body dysmorphic disorder (BDD) is suspected. Which of the following additional symptoms would support this diagnosis? (Select all that apply.)

1. Mirror checking
2. Excessive grooming
3. History of an eating disorder
4. History of delusional thinking
5. Skin picking

Answer 24

ANS: 1, 2, 5
Rationale: The DSM-5 lists preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others as a diagnostic criteria for the diagnosis of BDD. Also listed is that at some point during the course of the disorder, the person has performed repetitive behaviors, such as mirror checking, excessive grooming, skin picking, or reassurance seeking.