M31 Stress & Coping

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 31 Stress and Coping
The Concept of Stress and Coping
1) After a mammogram, a client is told that she needs a fine needle aspirate of a breast mass.
What demonstrates that the client is engaging in a primary appraisal of the stressful situation?
A) The client holds her breath while the nurse is talking.
B) The client sits in the dressing room and cries.
C) The client asks the nurse if she has cancer.
D) The client schedules the procedure in 6 weeks, which is the earliest possible appointment.
Answer: C
Explanation: A) In primary appraisal, the client assesses the potential for benefit, harm, loss,
threat, or challenge in a situation. The client asking the nurse if she has cancer is engaging in a
primary appraisal. The client holding her breath while the nurse is talking is evaluating coping
resources and options. This is a secondary appraisal. The client who sits in the dressing room and
cries is applying a coping resource. This is coping. The client who schedules the procedure at the
earliest possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of
the situation based on new information.
B) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or
challenge in a situation. The client asking the nurse if she has cancer is engaging in a primary
appraisal. The client holding her breath while the nurse is talking is evaluating coping resources
and options. This is a secondary appraisal. The client who sits in the dressing room and cries is
applying a coping resource. This is coping. The client who schedules the procedure at the earliest
possible appointment is engaging in reappraisal, which is an ongoing reinterpretation of the
situation based on new information.
C) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or
D) In primary appraisal, the client assesses the potential for benefit, harm, loss, threat, or
Page Ref: 1898
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiologic response to stress and the psychodynamics of
coping.
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2) A client says that learning how to use the blood glucose machine will have to wait until
holiday events are planned first. Which cognitive indication of stress is the client demonstrating?
A) Problem solving
B) Suppression
C) Self-control
D) Structuring
Answer: B
Explanation: A) The client is demonstrating suppression, which is the conscious and willful act
of putting a thought or feeling out of mind. The client is focusing on other needs and not the need
to learn how to use the blood glucose machine. Problem solving involves thinking through the
threatening situation, using specific steps to arrive at a solution. Structuring is the arrangement or
manipulation of a situation so that threatening events do not occur. Self-control is assuming a
manner and facial expression that convey a sense of being in control or in charge.
B) The client is demonstrating suppression, which is the conscious and willful act of putting a
thought or feeling out of mind. The client is focusing on other needs and not the need to learn
how to use the blood glucose machine. Problem solving involves thinking through the
C) The client is demonstrating suppression, which is the conscious and willful act of putting a
D) The client is demonstrating suppression, which is the conscious and willful act of putting a
Page Ref: 1904
Learning Outcome: 2. Examine the relationship between stress and coping and other
concepts/systems.
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3) A client worries every day about personal health and that they may not have enough
medication should the weather take a turn for the worse. The nurse is concerned that the client
might be developing which of the following?
A) Generalized anxiety disorder
B) Phobia
C) Obsessive-compulsive disorder
D) Panic disorder
Answer: A
Explanation: A) Generalized anxiety disorder is excessive worry about everyday problems, with
the anxiety being more intense than the situation warrants. The client is demonstrating signs of
generalized anxiety disorder. A phobia is an intense, persistent, irrational fear of a simple thing
or social situation that compels the individual to avoid the stressor that elicits the fear. Panic
disorder is a sudden attack of terror, accompanied by a pounding heart, sweatiness, weakness,
faintness, or dizziness. Obsessive-compulsive disorder is characterized by obsessive thoughts
and compulsive repetitive behaviors formed in response to the obsessive thoughts to lower the
level of anxiety experienced.
B) Generalized anxiety disorder is excessive worry about everyday problems, with the anxiety
being more intense than the situation warrants. The client is demonstrating signs of generalized
anxiety disorder. A phobia is an intense, persistent, irrational fear of a simple thing or social
situation that compels the individual to avoid the stressor that elicits the fear. Panic disorder is a
sudden attack of terror, accompanied by a pounding heart, sweatiness, weakness, faintness, or
dizziness. Obsessive-compulsive disorder is characterized by obsessive thoughts and compulsive
repetitive behaviors formed in response to the obsessive thoughts to lower the level of anxiety
experienced.
C) Generalized anxiety disorder is excessive worry about everyday problems, with the anxiety
experienced.
D) Generalized anxiety disorder is excessive worry about everyday problems, with the anxiety
experienced.
Page Ref: 1908
Learning Outcome: 3. Identify commonly occurring alterations in coping and their related
therapies.
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4) Which assessment finding or findings indicate to the nurse that a client is experiencing stress?
Select all that apply.
A) Chewing on a finger nail
B) Checking cellular phone
C) Reading a magazine
D) Talking with others
E) Tapping foot
Answer: A, E
Explanation: A) The client is experiencing both behavioral (nail chewing) and physical (foot
tapping) indications of stress. Reading a magazine, checking a phone, and talking with others are
not indications of stress.
B) The client is experiencing both behavioral (nail chewing) and physical (foot tapping)
indications of stress. Reading a magazine, checking a phone, and talking with others are not
indications of stress.
C) The client is experiencing both behavioral (nail chewing) and physical (foot tapping)
D) The client is experiencing both behavioral (nail chewing) and physical (foot tapping)
E) The client is experiencing both behavioral (nail chewing) and physical (foot tapping)
Page Ref: 1912
Learning Outcome: 4. Differentiate common assessment procedures used to examine stress
levels and coping mechanisms across the life span.
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5) The nurse suspects that a healthy client could be experiencing stress because of which
laboratory result?
A) Serum sodium of 142 mEq/L
B) Serum glucose of 165 mg/dL
C) Serum potassium of 4.0 mEq/L
D) Serum calcium of 10.2 mEq/L
Answer: B
Explanation: A) Laboratory tests are not routinely done to evaluate anxiety because observation
is faster and more accurate. However, they may be necessary to rule out medical conditions that
can cause anxiety. The elevated blood glucose level could indicate that the client is experiencing
stress because of an increase in adrenal function. One physiological indicator of stress is an
increase in blood glucose because of the release of glucocorticoids and gluconeogenesis. The
other laboratory values are within normal limits.
B) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and
more accurate. However, they may be necessary to rule out medical conditions that can cause
anxiety. The elevated blood glucose level could indicate that the client is experiencing stress
because of an increase in adrenal function. One physiological indicator of stress is an increase in
blood glucose because of the release of glucocorticoids and gluconeogenesis. The other
laboratory values are within normal limits.
C) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and
D) Laboratory tests are not routinely done to evaluate anxiety because observation is faster and
Page Ref: 1906
Cognitive Level: Understanding
Client Need: Physiological Integrity
Learning Outcome: 4. Differentiate common assessment procedures used to examine stress
levels and coping mechanisms across the life span.
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6) A client complains about the stress of having to work so much and missing daily exercise
routines. What should the nurse respond to this client?
A) "There are other ways to reduce stress, such as meditation."
B) "Exercise helps reduce the impact of stress on the body and would be a good thing."
C) "Drinking a small glass of wine each day does help reduce stress."
D) "Maybe exercising, with all of the work, would be too much for your body anyway."
Answer: B
Explanation: A) The client had been exercising but has not because of additional work, which is
causing stress. The nurse should encourage the client to resume daily exercise to reduce the
impact of the stress on the body. The nurse should not reinforce the client's not exercising.
Meditation might be beneficial, but because the client mentioned initially exercising and not
meditating, this suggestion is not as appropriate in addressing the client's needs. The nurse
should not suggest using alcohol to deal with stress.
B) The client had been exercising but has not because of additional work, which is causing
stress. The nurse should encourage the client to resume daily exercise to reduce the impact of the
stress on the body. The nurse should not reinforce the client's not exercising. Meditation might
be beneficial, but because the client mentioned initially exercising and not meditating, this
suggestion is not as appropriate in addressing the client's needs. The nurse should not suggest
using alcohol to deal with stress.
C) The client had been exercising but has not because of additional work, which is causing
D) The client had been exercising but has not because of additional work, which is causing
Page Ref: 1914
Cognitive Level: Applying
Nursing Process: Implementation
Learning Outcome: 6. Explain management of stress to facilitate healthy coping and prevent
stress-related illness.
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7) Which intervention would help a client who is demonstrating stress about being hospitalized
and concerned about the needs of the children at home?
A) Ask the client if there is anything that is needed once discharged to home.
B) Ask the client if there is anyone who would be able to help with the family needs at home
during recuperation.
C) Find out if the children can be sent to a grandparent's home until the client fully recovers.
D) Suggest the client be transferred to a long-term care facility to ensure a full recovery.
Answer: B
Explanation: A) The best way that the nurse can help the client who is stressed with a new
illness and family responsibilities is to ask if there is anyone who can help the client at home.
Transferring the client to a long-term care facility will not help the client with the stress of caring
for a family at home. Sending the children to a grandparent's home might not work if the
children are in school and the grandparent lives far away. Asking the client if there is anything
that is needed once discharged is not enough. The nurse needs to do something else.
B) The best way that the nurse can help the client who is stressed with a new illness and family
responsibilities is to ask if there is anyone who can help the client at home. Transferring the
client to a long-term care facility will not help the client with the stress of caring for a family at
home. Sending the children to a grandparent's home might not work if the children are in school
and the grandparent lives far away. Asking the client if there is anything that is needed once
discharged is not enough. The nurse needs to do something else.
C) The best way that the nurse can help the client who is stressed with a new illness and family
D) The best way that the nurse can help the client who is stressed with a new illness and family
Page Ref: 1914
Learning Outcome: 6. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in coping.
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8) Which of the following should the nurse instruct a client prescribed diazepam (Valium) for
anxiety and stress?
A) "This medication will be good to take for a long time."
B) "Take this medication every time feelings of stress become overwhelming."
C) "This medication works best if taken with a meal."
D) "This medication is good to use for the short term only."
Answer: D
Explanation: A) Diazepam (Valium) is a benzodiazepine that is typically used for short-term
treatment during an acute phase of an anxiety disorder. It may be effective in quickly lowering
the severity of a client's anxiety but is generally not recommended for use beyond a few weeks
because of its addictive properties. The nurse should instruct the client that the medication is
good to use for the short term only. There is no indication that this medication needs to be taken
with a meal. Instructing the client to take the medication every time feelings of stress become
overwhelming could lead to an overdose and should not be done.
B) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during
an acute phase of an anxiety disorder. It may be effective in quickly lowering the severity of a
client's anxiety but is generally not recommended for use beyond a few weeks because of its
addictive properties. The nurse should instruct the client that the medication is good to use for
the short term only. There is no indication that this medication needs to be taken with a meal.
Instructing the client to take the medication every time feelings of stress become overwhelming
could lead to an overdose and should not be done.
C) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during
D) Diazepam (Valium) is a benzodiazepine that is typically used for short-term treatment during
Page Ref: 1916
Learning Outcome: 7. Compare and contrast common independent and collaborative
interventions for clients with alterations in coping.
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9) The nurse is assessing a client who is demonstrating physiologic manifestations of a stress
response. Which physiologic manifestations are the result of the inhibition of the
parasympathetic nervous system?
A) Dry oral mucous membranes
B) Hypoactive bowel sounds
C) Increased heart rate
D) Increased respiratory rate
E) Increased depth of respirations
Answer: A, B
Explanation: A) Dry mouth is secondary to inhibition of the parasympathetic nervous system;
therefore assessment findings would reveal dry oral mucous membranes. Inhibition of the
parasympathetic nervous system leads to decreased peristalsis; therefore assessment findings
would indicate hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of
respirations are all due to sympathetic nervous system stimulation.
B) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore
assessment findings would reveal dry oral mucous membranes. Inhibition of the parasympathetic
nervous system leads to decreased peristalsis; therefore assessment findings would indicate
hypoactive bowel sounds. Increased heart rate, respiratory rate, and depth of respirations are all
due to sympathetic nervous system stimulation.
C) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore
D) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore
E) Dry mouth is secondary to inhibition of the parasympathetic nervous system; therefore
Page Ref: 1986
Client Need Sub: Physiological Adaptation
Learning Outcome: 1. Summarize the physiologic response to stress and the psychodynamics of
coping.
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10) A client has just started taking risperidone (Risperdal) as ordered by the physician. Which
would be a priority nursing consideration for this client?
A) Assess blood pressure and heart rate.
B) Monitor for increased agitation.
C) Assess for drowsiness.
D) Monitor for neuroleptic syndrome.
Answer: D
Explanation: A) Monitoring for neuroleptic syndrome is a priority nursing consideration for a
client taking risperidone (Risperdal). The nurse must monitor for signs and symptoms of
neuroleptic malignant syndrome and tardive dyskinesia and immediately report signs and
symptoms of these conditions. Monitoring for increased agitation and assessing for drowsiness
are nursing considerations for clients taking Risperdal, but they are not the priority diagnosis.
Assessing blood pressure and heart rate would be a priority nursing consideration for the client
taking Inderal.
B) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking
risperidone (Risperdal). The nurse must monitor for signs and symptoms of neuroleptic
malignant syndrome and tardive dyskinesia and immediately report signs and symptoms of these
conditions. Monitoring for increased agitation and assessing for drowsiness are nursing
considerations for clients taking Risperdal, but they are not the priority diagnosis. Assessing
blood pressure and heart rate would be a priority nursing consideration for the client taking
Inderal.
C) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking
Inderal.
D) Monitoring for neuroleptic syndrome is a priority nursing consideration for a client taking
Inderal.
Page Ref: 1916
Client Need Sub: Pharmacological and Parenteral Therapies
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in coping.
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11) A nurse on the behavioral health unit is caring for a client diagnosed with depression, who
just lost his spouse in a motor-vehicle accident. The client states to the nurse, "my wife would
not have wanted to live if she were disabled." This statement indicates to the nurse that the client
is using which defense mechanism?
A) Identification
B) Denial
C) Intellectualization
D) Displacement
Answer: C
Explanation: A) Intellectualization is a mechanism by which an emotional response that
normally would accompany an uncomfortable or painful incident is evaded by the use of rational
explanations that remove from the incident any personal significance and feelings. Identification
is an attempt to manage anxiety by imitating the behavior of someone feared or respected. Denial
is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them.
Displacement is the transferring or discharging of emotional reactions from one object or
individual to another object or individual.
B) Intellectualization is a mechanism by which an emotional response that normally would
accompany an uncomfortable or painful incident is evaded by the use of rational explanations
that remove from the incident any personal significance and feelings. Identification is an attempt
to manage anxiety by imitating the behavior of someone feared or respected. Denial is an attempt
to screen or ignore unacceptable realities by refusing to acknowledge them. Displacement is the
transferring or discharging of emotional reactions from one object or individual to another object
or individual.
C) Intellectualization is a mechanism by which an emotional response that normally would
or individual.
D) Intellectualization is a mechanism by which an emotional response that normally would
or individual.
Page Ref: 1905
Learning Outcome: 6. Explain management of stress to facilitate healthy coping and prevent
stress-related illness.
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Exemplar 31.1 Anxiety Disorders
1) A client who has been experiencing slight anxiety is now trembling and communicating in a
manner that makes it difficult for the nurse to understand the client's needs. The nurse is
concerned that the client has progressed to which level of anxiety?
A) Panic
B) Severe
C) Moderate
D) Mild
Answer: B
Explanation: A) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety
causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes.
At severe levels, communication is difficult to understand and trembling can occur.
Communication may not be understandable at all when the client reaches the panic stage.
B) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an
increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe
levels, communication is difficult to understand and trembling can occur. Communication may
not be understandable at all when the client reaches the panic stage.
C) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an
D) Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an
Page Ref: 1923
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of anxiety disorders.
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2) A client tells the nurse about recently being laid off from work and is scheduled for a biopsy
to detect a malignancy. What should the nurse include when planning this client's care?
A) Reasons to delay the biopsy
B) Medicate around the clock for pain
C) Interventions to address anxiety
D) Social services to aid with financial planning
Answer: C
Explanation: A) Risk factors for anxiety disorders include multiple stressors such as an illness
occurring with a change in employment. The nurse should plan interventions to address anxiety.
Social services may or may not be needed for the client's financial planning. Delaying the biopsy
will not help reduce anxiety. There is no evidence to suggest the client is experiencing pain.
B) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with
a change in employment. The nurse should plan interventions to address anxiety. Social services
may or may not be needed for the client's financial planning. Delaying the biopsy will not help
reduce anxiety. There is no evidence to suggest the client is experiencing pain.
C) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with
D) Risk factors for anxiety disorders include multiple stressors such as an illness occurring with
Page Ref: 1920
Nursing Process: Planning
Learning Outcome: 2. Identify risk factors and prevention methods associated with anxiety
disorders.
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3) While caring for a critically ill child, the child's mother becomes distraught and begins to cry
loudly while stroking the child's face. What is the best nurse response to the mother's behavior?
A) Explain the procedure that will occur with the treatment.
B) Tell the mother that she needs to control herself for the benefit of her child.
C) Take the mother out of the room and comfort her.
D) Distract the mother by having her straighten the linens on the bed.
Answer: C
Explanation: A) In this situation, the nurse must analyze which of the available options would
be best for this mother and child. At this level of emotion, the nurse should remove the mother
from the room and comfort her. Although the mother's expression of anxiety is understandable,
the child should be protected from this strongly upsetting situation. Just telling the mother to
control herself discounts the seriousness of her anxiety and may serve to alienate the mother
from the nurse. This mother is too upset to distract by smoothing linens. Explaining the
procedure may help, but the mother should be removed at least temporarily and be comforted so
that she will be able to receive the information.
B) In this situation, the nurse must analyze which of the available options would be best for this
mother and child. At this level of emotion, the nurse should remove the mother from the room
and comfort her. Although the mother's expression of anxiety is understandable, the child should
be protected from this strongly upsetting situation. Just telling the mother to control herself
discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse.
This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but
the mother should be removed at least temporarily and be comforted so that she will be able to
receive the information.
C) In this situation, the nurse must analyze which of the available options would be best for this
D) In this situation, the nurse must analyze which of the available options would be best for this
Page Ref: 1926
Learning Outcome: 3. Illustrate the nursing process in providing culturally sensitive care across
the life span for individuals with anxiety disorders.
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4) While attempting to choose a nursing diagnosis, the nurse must decide whether a client is
experiencing anxiety or fear. What key point would help the nurse make this decision?
A) The source of fear is identifiable, but anxiety may be vague.
B) Anxiety is a milder form of fear.
C) Fear results in a physiologic response, whereas anxiety is psychological.
D) Anxiety is generally based in reality, whereas fear is not.
Answer: A
Explanation: A) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can
both be based in reality or may not be based in reality. Both fear and anxiety can have
physiologic and psychological components. Fear and anxiety are different, so anxiety is not just a
milder form of fear.
B) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in
reality or may not be based in reality. Both fear and anxiety can have physiologic and
psychological components. Fear and anxiety are different, so anxiety is not just a milder form of
fear.
C) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in
fear.
D) The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in
fear.
Page Ref: 1903-1904
Nursing Process: Diagnosis
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
an anxiety disorder.
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5) Which nursing intervention minimizes the stress and anxiety of hospitalization for a client?
A) Explain all procedures in detail before performing them.
B) Control the environment of healing.
C) Demonstrate staff competence by using multiple nurses for care.
D) Let the client make the majority of decisions about the plan of care.
Answer: B
Explanation: A) The nurse is in charge of the environment of healing and should take
responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to
care for one client, and keeping the area clean and comfortable. Explaining all procedures in
detail may overwhelm the client. Using short, clear sentences and explaining only enough to
satisfy the client is a better plan. A client who is ill cannot be expected to make the majority of
decisions about the plan of care, but should be allowed as much autonomy and choice as can be
arranged and tolerated.
B) The nurse is in charge of the environment of healing and should take responsibility for
limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client,
and keeping the area clean and comfortable. Explaining all procedures in detail may overwhelm
the client. Using short, clear sentences and explaining only enough to satisfy the client is a better
plan. A client who is ill cannot be expected to make the majority of decisions about the plan of
care, but should be allowed as much autonomy and choice as can be arranged and tolerated.
C) The nurse is in charge of the environment of healing and should take responsibility for
D) The nurse is in charge of the environment of healing and should take responsibility for
Page Ref: 1926
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with an anxiety disorder.
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6) The nurse realizes that medication teaching has been ineffective when the client with an
anxiety disorder states, "Prozac is not working, even though I have been taking it for
A) 4 weeks."
B) 1 week."
C) 8 weeks."
D) 12 weeks."
Answer: B
Explanation: A) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI).
Typically, this classification of medications takes 4 weeks to demonstrate a therapeutic response
and up to 8-12 weeks to see a full response to the drug.
B) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this
classification of medications takes 4 weeks to demonstrate a therapeutic response and up to 8-12
weeks to see a full response to the drug.
C) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this
D) Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). Typically, this
Page Ref: 1916
Nursing Process: Evaluation
Learning Outcome: 6. Plan evidence-based care for an individual with an anxiety disorder and
his or her family in collaboration with other members of the healthcare team.
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7) The nurse is instructing a client with an anxiety disorder on behavioral tools to help with
coping. What would the nurse include in this teaching?
A) Reading self-help literature
B) Thought stopping
C) Journaling
D) Distraction
E) Practicing yoga
Answer: A, C, E
Explanation: A) Behavioral tools to help with coping include reading self-help literature,
practicing relaxation techniques such as yoga, and journaling stressors and emotional responses
and alternatives. Thought stopping and distraction are cognitive coping tools.
B) Behavioral tools to help with coping include reading self-help literature, practicing relaxation
techniques such as yoga, and journaling stressors and emotional responses and alternatives.
Thought stopping and distraction are cognitive coping tools.
C) Behavioral tools to help with coping include reading self-help literature, practicing relaxation
D) Behavioral tools to help with coping include reading self-help literature, practicing relaxation
E) Behavioral tools to help with coping include reading self-help literature, practicing relaxation
Page Ref: 1925
Learning Outcome: 7. Evaluate expected outcomes for an individual with an anxiety disorder.
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8) What should the nurse do first when a client begins to demonstrate signs of escalating
anxiety?
A) Isolate the client in a safe, quiet, and protective environment.
B) Leave the client alone in a room.
C) Provide a benzodiazepine.
D) Phone the physician.
Answer: A
Explanation: A) The nurse should first isolate the severely anxious or panicked client in a safe,
quiet, protective environment. The nurse should not leave the client unattended. Phoning the
physician may not be helpful to the client. Medications can be provided once the client is in a
safe, protective environment.
B) The nurse should first isolate the severely anxious or panicked client in a safe, quiet,
protective environment. The nurse should not leave the client unattended. Phoning the physician
may not be helpful to the client. Medications can be provided once the client is in a safe,
protective environment.
C) The nurse should first isolate the severely anxious or panicked client in a safe, quiet,
D) The nurse should first isolate the severely anxious or panicked client in a safe, quiet,
Page Ref: 1926
Learning Outcome: 6. Plan evidence-based care for an individual with an anxiety disorder and
his or her family in collaboration with other members of the healthcare team.
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9) The nurse is admitting a client with panic anxiety to the behavioral health unit. Which clinical
manifestation(s) would indicate that the client's anxiety is at a panic level of severity?
A) Inability to focus
B) Dilated pupils
C) Feelings of doom
D) Self-absorption
E) Rapid speech
Answer: A, B, C
Explanation: A) An inability to focus, dilated pupils, and a feeling of doom are clinical
manifestations that a client could experience at the panic level of severity of anxiety. Self-
absorption and rapid speech could indicate that a client is experiencing anxiety at a moderate
level of severity.
B) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a
client could experience at the panic level of severity of anxiety. Self-absorption and rapid speech
could indicate that a client is experiencing anxiety at a moderate level of severity.
C) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a
D) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a
E) An inability to focus, dilated pupils, and a feeling of doom are clinical manifestations that a
Page Ref: 1923
direct and indirect causes of anxiety disorders.
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10) A nurse on the behavioral health unit is leading a group regarding risk factors for anxiety. At
the completion of group work, which comment made by a client would indicate the need for
further teaching?
A) "A lack of social interaction places me at risk for anxiety."
B) "My personality could place me at risk for anxiety because I am shy."
C) "Chronic illness is not a risk factor unless I am also unemployed."
D) "I experienced a traumatic event that placed me at risk for having this anxiety disorder."
Answer: C
Explanation: A) Chronic illness is a risk factor for anxiety disorders with or without the
unemployment factor. For some clients multiple stressors, such as chronic illness with loss of
employment, are risk factors. So this statement indicates a need for further teaching. The other
statements are accurate and therefore do not require further teaching.
B) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor.
For some clients multiple stressors, such as chronic illness with loss of employment, are risk
factors. So this statement indicates a need for further teaching. The other statements are accurate
and therefore do not require further teaching.
C) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor.
D) Chronic illness is a risk factor for anxiety disorders with or without the unemployment factor.
Page Ref: 1920
Nursing Process: Teaching and Learning
Learning Outcome: 2. Identify risk factors and prevention methods associated with anxiety
disorders.
21
11) The nurse is discharging a client diagnosed with general anxiety disorder (GAD). The client
is prescribed a selective serotonin reuptake inhibitor (SSRI). Which statement made by the client
would indicate to the nurse a need for further education?
A) "This medicine could make me feel like I have the jitters."
B) "I may experience some nausea while on this medication."
C) "The physician will start me off on a high dose and then decrease the dose."
D) "This medicine alters the levels of the neurotransmitter serotonin in the brain."
Answer: C
Explanation: A) SSRIs are generally started at low doses and then increased as their
effectiveness becomes apparent; therefore this statement made by the client is inaccurate and
does indicate a lack of understanding and the need for further teaching. The other statements are
accurate so do not require further teaching.
B) SSRIs are generally started at low doses and then increased as their effectiveness becomes
apparent; therefore this statement made by the client is inaccurate and does indicate a lack of
understanding and the need for further teaching. The other statements are accurate so do not
require further teaching.
C) SSRIs are generally started at low doses and then increased as their effectiveness becomes
D) SSRIs are generally started at low doses and then increased as their effectiveness becomes
Page Ref: 1924
care of an individual with an anxiety disorder.
22
Exemplar 31.2 Crisis
1) A client is "in crisis" because he has just been fired from his job, his spouse wants a divorce,
and he has been sick with a cold for 1 month. Which nursing statement demonstrates
understanding of the care of a client in crisis?
A) "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as
possible."
B) "People generally find it easier to work through a crisis if someone is working with them."
C) "Men often handle crisis better individually, whereas women do better with a counselor."
D) "Once you reach the crisis state, you may remain there for several months until you recover."
Answer: B
Explanation: A) In general, people are more successful in working through a crisis if they have
someone to help them. This need for help is not gender dependent. A crisis results in such a state
of disequilibrium that it is generally self-limiting and not a long-term event. Experiencing a crisis
may actually offer the family or individual a potential for growth and change.
B) In general, people are more successful in working through a crisis if they have someone to
help them. This need for help is not gender dependent. A crisis results in such a state of
disequilibrium that it is generally self-limiting and not a long-term event. Experiencing a crisis
C) In general, people are more successful in working through a crisis if they have someone to
D) In general, people are more successful in working through a crisis if they have someone to
Page Ref: 1928
Learning Outcome: 1. Describe the physiology, etiology, clinical manifestations, and direct and
indirect causes of a crisis response.
23
2) After an assessment, the nurse determines that an 18-year-old client is experiencing a
maturational crisis because of which findings?
A) Relationship with significant other ended
B) Inability to focus on school studies
C) Cannot sleep at night and skips classes
D) Recent death of a friend
E) Graduating from high school in 2 months
Answer: B, C, E
Explanation: A) Senior year is a transition to work or college. This is a developmental
progression to the next level of maturity, a predictable event experienced by nearly all
individuals. The client is demonstrating stressors unique to progressing to the next level of
maturity. The recent death of a friend and having a relationship with a significant other end are
situational crises.
B) Senior year is a transition to work or college. This is a developmental progression to the next
level of maturity, a predictable event experienced by nearly all individuals. The client is
demonstrating stressors unique to progressing to the next level of maturity. The recent death of a
friend and having a relationship with a significant other end are situational crises.
C) Senior year is a transition to work or college. This is a developmental progression to the next
D) Senior year is a transition to work or college. This is a developmental progression to the next
E) Senior year is a transition to work or college. This is a developmental progression to the next
Page Ref: 1928
Learning Outcome: 2. Identify risk factors and prevention methods associated with crisis.
24
3) What is the appropriate nurse response for a client experiencing a situational crisis?
A) "I know just how you feel."
B) "I am sorry this happened to you."
C) "It's best to stay busy."
D) "Things will get better and you will feel better."
E) "It could have been worse."
Answer: B, D
Explanation: A) Stating that the nurse is sorry for what the client has experienced reflects
empathy. Saying that things will get better and the client will feel better provides hope.
Assessing the client's current emotional state and coping mechanisms that have been effective in
the past requires open-ended questions and attentive listening. Stating that the nurse knows how
the client feels hinders this communication and takes the focus off the client. Telling the client to
stay busy does not empower the client to identify and adopt coping strategies. Telling the client it
could have been worse minimizes the client's unique experience.
B) Stating that the nurse is sorry for what the client has experienced reflects empathy. Saying
that things will get better and the client will feel better provides hope. Assessing the client's
current emotional state and coping mechanisms that have been effective in the past requires
open-ended questions and attentive listening. Stating that the nurse knows how the client feels
hinders this communication and takes the focus off the client. Telling the client to stay busy does
not empower the client to identify and adopt coping strategies. Telling the client it could have
been worse minimizes the client's unique experience.
C) Stating that the nurse is sorry for what the client has experienced reflects empathy. Saying
D) Stating that the nurse is sorry for what the client has experienced reflects empathy. Saying
25
E) Stating that the nurse is sorry for what the client has experienced reflects empathy. Saying
Page Ref: 1928
the life span for individuals in crisis.
4) Which nursing diagnosis would be applicable for a client having experienced a situational
crisis?
A) Ineffective Coping
B) Risk for Self-Directed Violence
C) Spiritual Distress
D) Risk for Loneliness
Answer: A, B, C
Explanation: A) Loneliness may result from an individual's actions following a crisis, but it is
not an appropriate nursing diagnosis for situational crisis. The other three answers are among the
most common nursing diagnoses for people in crisis.
B) Loneliness may result from an individual's actions following a crisis, but it is not an
appropriate nursing diagnosis for situational crisis. The other three answers are among the most
common nursing diagnoses for people in crisis.
C) Loneliness may result from an individual's actions following a crisis, but it is not an
D) Loneliness may result from an individual's actions following a crisis, but it is not an
Page Ref: 1932-1933
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual in
crisis.
26
5) When planning interventions to address a client's crisis, what should the nurse do?
A) Develop the plan prior to meeting with the client.
B) Conduct a complete assessment.
C) Determine follow-up.
D) Focus on long-term problems.
Answer: B
Explanation: A) Nursing care is based on assessment. Thus, a plan cannot be developed prior to
meeting with the client. The time frame, whether short term or long term, and the need for
follow- up will be determined by the findings of the assessment.
B) Nursing care is based on assessment. Thus, a plan cannot be developed prior to meeting with
the client. The time frame, whether short term or long term, and the need for follow-up will be
determined by the findings of the assessment.
C) Nursing care is based on assessment. Thus, a plan cannot be developed prior to meeting with
D) Nursing care is based on assessment. Thus, a plan cannot be developed prior to meeting with
Page Ref: 1933
Learning Outcome: 6. Plan evidence-based care for an individual in crisis and his or her family
in collaboration with other members of the healthcare team.
27
6) A client divorced for 1 year has begun to take classes at a community college and has enrolled
the children in daycare. These new actions could be referred to as a
A) turning point in life.
B) maturational crisis.
C) situational crisis.
D) response to stress.
Answer: A
Explanation: A) Crisis situations such as a divorce can become turning points or junctures in life
that result in a change in equilibrium, positive or negative. The client may have experienced a
situational crisis and stress, but the events of the client's last year have resulted in a turning point.
A maturational crisis is a developmental progression to the next level of maturity, a predictable
event experienced by nearly all individuals.
B) Crisis situations such as a divorce can become turning points or junctures in life that result in
a change in equilibrium, positive or negative. The client may have experienced a situational
crisis and stress, but the events of the client's last year have resulted in a turning point. A
maturational crisis is a developmental progression to the next level of maturity, a predictable
C) Crisis situations such as a divorce can become turning points or junctures in life that result in
D) Crisis situations such as a divorce can become turning points or junctures in life that result in
Page Ref: 1928
Learning Outcome: 7. Evaluate expected outcomes for an individual in crisis.
28
7) The nurse is beginning crisis counseling with a client. What action(s) will the nurse utilize
when counseling the client?
A) Assist in coping with the problem.
B) Conduct follow-up assessments.
C) Boil down the problem.
D) Achieve contact.
E) Assess physiologic status.
Answer: A, C, D
Explanation: A) When conducting crisis counseling with a client, the nurse will achieve contact,
boil down the problem, and assist the client in coping with the problem. Assessing physiologic
status and conducting follow-up assessments are not steps within crisis counseling.
B) When conducting crisis counseling with a client, the nurse will achieve contact, boil down the
problem, and assist the client in coping with the problem. Assessing physiologic status and
conducting follow-up assessments are not steps within crisis counseling.
C) When conducting crisis counseling with a client, the nurse will achieve contact, boil down the
D) When conducting crisis counseling with a client, the nurse will achieve contact, boil down the
E) When conducting crisis counseling with a client, the nurse will achieve contact, boil down the
Page Ref: 1930
care of an individual in crisis.
29
8) The nurse is working with a family that has just survived a tornado. As part of the
intervention, the nurse is reviewing emotions family members may be experiencing that are
considered normal reactions to a traumatic event. Which conclusions does the nurse make?
A) All family members will process the experience at about the same pace.
B) Each member of the family has a different way of coping.
C) Each family member talks to the nurse openly and freely.
D) All family members will experience anxiety about self and family safety.
E) Some family members have difficulty accepting help.
Answer: B, D, E
Explanation: A) Anxiety about self and family's safety is an initial reaction after an individual's
safety has been in jeopardy. Each member of the family has a different way of coping. Family
members are all at different levels of maturity and have different coping skills. Some family
members have difficulty accepting help. Different family members will respond in various ways
to offers of help due to each person's individuality and coping style. Communication is difficult
for most clients after a sudden crisis, so it is unlikely that they will talk to the nurse openly and
freely. All family members will process the experience at about the same pace is incorrect
because family members' different maturity levels and coping skills will affect how quickly or
slowly they process the experience.
B) Anxiety about self and family's safety is an initial reaction after an individual's safety has
been in jeopardy. Each member of the family has a different way of coping. Family members are
all at different levels of maturity and have different coping skills. Some family members have
difficulty accepting help. Different family members will respond in various ways to offers of
help due to each person's individuality and coping style. Communication is difficult for most
clients after a sudden crisis, so it is unlikely that they will talk to the nurse openly and freely. All
family members will process the experience at about the same pace is incorrect because family
members' different maturity levels and coping skills will affect how quickly or slowly they
process the experience.
C) Anxiety about self and family's safety is an initial reaction after an individual's safety has
D) Anxiety about self and family's safety is an initial reaction after an individual's safety has
30
E) Anxiety about self and family's safety is an initial reaction after an individual's safety has
Page Ref: 1930
31
9) A nurse is caring for a client in crisis. While providing care it is imperative that the nurse
communicates effectively with this client. Which is true when communicating with clients in
crisis?
A) Communication should be frequent.
B) Communication should be brief.
C) Communication should be simple.
D) Communication should be detailed.
E) Communication should be directive.
Answer: A, B, C, E
Explanation: A) Communicating with individuals in crisis requires frequent, brief, simple, and
often directive communication. Biologically speaking, the brain of the individual in crisis is in
the process of being bombarded with electrochemical reactions. Concentration and the ability to
remember and retain information can be impaired.
B) Communicating with individuals in crisis requires frequent, brief, simple, and often directive
communication. Biologically speaking, the brain of the individual in crisis is in the process of
being bombarded with electrochemical reactions. Concentration and the ability to remember and
retain information can be impaired.
C) Communicating with individuals in crisis requires frequent, brief, simple, and often directive
D) Detailed communication would be contraindicated. Communicating with individuals in crisis
requires frequent, brief, simple, and often directive communication. Biologically speaking, the
brain of the individual in crisis is in the process of being bombarded with electrochemical
reactions. Concentration and the ability to remember and retain information can be impaired.
E) Communicating with individuals in crisis requires frequent, brief, simple, and often directive
Page Ref: 1930
Nursing Process: Communication
32
10) A clinic nurse is assessing a client who is experiencing crisis. The nurse needs to determine
the client's immediate needs. Which action would the nurse recognize to be the priority
intervention?
A) Scan for physical distress.
B) Explore perceptions of the crisis.
C) Develop a follow-up plan.
D) Assess for immediate safety needs.
Answer: D
Explanation: A) Assessing for immediate safety needs would take priority. An example of this
would be a client coming into the clinic in crisis because she was violently abused by a
significant other. It would be imperative for the nurse to determine the immediate safety needs of
the client before proceeding. Scanning for physical distress and exploring perceptions of the
crisis are important, but do not take priority over safety. Developing a follow-up plan would
occur only after other interventions have been implemented.
B) Assessing for immediate safety needs would take priority. An example of this would be a
client coming into the clinic in crisis because she was violently abused by a significant other. It
would be imperative for the nurse to determine the immediate safety needs of the client before
proceeding. Scanning for physical distress and exploring perceptions of the crisis are important,
but do not take priority over safety. Developing a follow-up plan would occur only after other
interventions have been implemented.
C) Assessing for immediate safety needs would take priority. An example of this would be a
D) Assessing for immediate safety needs would take priority. An example of this would be a
Page Ref: 1932
33
11) The nurse determines that a client experiencing a crisis has not met goals when the client
makes which comment?
A) "I came up with some ideas on how to cope when I am in this position."
B) "I feel like I am in control and can begin managing things now."
C) "I am not sure whom I am going to call when I start feeling like this again."
D) "I can deal with this, I am a strong person, and I have a lot of friends and family."
Answer: C
Explanation: A) The client who is unsure of who to call in a crisis has not met goals yet. The
other statements demonstrate a good understanding of managing a crisis.
B) The client who is unsure of who to call in a crisis has not met goals yet. The other statements
demonstrate a good understanding of managing a crisis.
C) The client who is unsure of who to call in a crisis has not met goals yet. The other statements
D) The client who is unsure of who to call in a crisis has not met goals yet. The other statements
Page Ref: 1933
34
Exemplar 31.3 Obsessive-Compulsive Disorder
1) The nurse is concerned that a client is demonstrating signs of obsessive-compulsive disorder

when what was assessed?
A) Not making eye contact with the nurse
B) Female age 25
C) Client checking the contents of a purse several times within minutes
D) Client repeating the words "third floor"
E) Client asking to use the bathroom in the middle of the assessment
Answer: B, C, D
Explanation: A) Obsessive-compulsive disorder affects men and women equally; however,
women develop the disorder between the ages of 20 and 29. Repeating an action is one
manifestation of the disorder. Repeating specific words is a manifestation of the disorder. Lack
of eye contact and using the bathroom during an assessment are not manifestations of the
disorder.
B) Obsessive-compulsive disorder affects men and women equally; however, women develop
the disorder between the ages of 20 and 29. Repeating an action is one manifestation of the
disorder. Repeating specific words is a manifestation of the disorder. Lack of eye contact and
using the bathroom during an assessment are not manifestations of the disorder.
C) Obsessive-compulsive disorder affects men and women equally; however, women develop
D) Obsessive-compulsive disorder affects men and women equally; however, women develop
E) Obsessive-compulsive disorder affects men and women equally; however, women develop the
disorder between the ages of 20 and 29. Repeating an action is one manifestation of the disorder.
Repeating specific words is a manifestation of the disorder. Lack of eye contact and using the
bathroom during an assessment are not manifestations of the disorder.
Page Ref: 1935
direct and indirect causes of obsessive-compulsive disorder (OCD).
35
2) A parent says to the nurse, "I think my son is showing signs of obsessive-compulsive disorder,
just like my father." The nurse identifies which of the following as being a risk factor for the
development of this disorder?
A) Lives with parents
B) Male gender
C) Unemployed
D) History of chronic illnesses
E) Family history
Answer: B, E
Explanation: A) Risk factors for obsessive-compulsive disorder include a family history and a
major life stressor. Men develop the disorder earlier, between the ages of 6 and 15. Living with
parents, being unemployed, or having a history of chronic illnesses are not risk factors for the
disorder.
B) Risk factors for obsessive-compulsive disorder include a family history and a major life
stressor. Men develop the disorder earlier, between the ages of 6 and 15. Living with parents,
being unemployed, or having a history of chronic illnesses are not risk factors for the disorder.
C) Risk factors for obsessive-compulsive disorder include a family history and a major life
D) Risk factors for obsessive-compulsive disorder include a family history and a major life
E) Risk factors for obsessive-compulsive disorder include a family history and a major life
Page Ref: 1935
Learning Outcome: 2. Identify risk factors and prevention methods associated with OCD.
36
3) When caring for a client newly diagnosed with obsessive-compulsive disorder, it is most
important for the nurse to do which of the following?
A) Do not interrupt the ritual.
B) Interrupt the ritual.
C) Teach about antianxiety foods.
D) Teach ritual interruption skills.
Answer: A
Explanation: A) Do not interrupt the ritual because the client may feel compelled to start from
the beginning. For the newly diagnosed client, teaching ritual interruption skills and teaching
about antianxiety foods would not be the priority.
B) Do not interrupt the ritual because the client may feel compelled to start from the beginning.
For the newly diagnosed client, teaching ritual interruption skills and teaching about antianxiety
foods would not be the priority.
C) Do not interrupt the ritual because the client may feel compelled to start from the beginning.
D) Do not interrupt the ritual because the client may feel compelled to start from the beginning.
Page Ref: 1938
the life span for individuals with OCD.
37
4) The son of an elderly client with obsessive-compulsive disorder tells the nurse that he wants to
contact the fire department to report his mother because the house is nothing but boxes and bags
of saved items. What is the most appropriate nursing diagnosis for this situation?
A) Ineffective Coping
B) Deficient Knowledge
C) Risk for Caregiver Role Strain
D) Anxiety
Answer: C
Explanation: A) The son is experiencing anxiety about the client's obsessive-compulsive
behavior, which indicates a risk for caregiver role strain. There is not enough information to
determine whether or not the client or son is experiencing ineffective coping, anxiety, or
deficient knowledge.
B) The son is experiencing anxiety about the client's obsessive-compulsive behavior, which
indicates a risk for caregiver role strain. There is not enough information to determine whether or
not the client or son is experiencing ineffective coping, anxiety, or deficient knowledge.
C) The son is experiencing anxiety about the client's obsessive-compulsive behavior, which
D) The son is experiencing anxiety about the client's obsessive-compulsive behavior, which
Page Ref: 1937
OCD.
38
5) The home care nurse observes a client scrubbing areas throughout the house over and over,
especially areas where the family gathers. What should the nurse assess prior to planning care for
this client?
A) If the client is forgetful
B) If the client vomits during cleaning
C) How frequently the client cleans the house
D) The impact of symptoms on the family system
Answer: D
Explanation: A) Obsessive-compulsive disorder impacts the family system, especially with
impaired role function. How frequently the client cleans the house and whether vomiting occurs
during cleaning may be important to assess, but they are not the most important. Forgetfulness is
not a component of obsessive-compulsive disorder.
B) Obsessive-compulsive disorder impacts the family system, especially with impaired role
function. How frequently the client cleans the house and whether vomiting occurs during
cleaning may be important to assess, but they are not the most important. Forgetfulness is not a
component of obsessive-compulsive disorder.
C) Obsessive-compulsive disorder impacts the family system, especially with impaired role
D) Obsessive-compulsive disorder impacts the family system, especially with impaired role
Page Ref: 1936
39
6) What would indicate that treatment for a client with obsessive-compulsive disorder is
effective?
A) The client watches television while eating meals and engages in conversation with a
roommate.
B) The client conducts ritualistic hand washing every hour.
C) While walking, the client counts 13 steps and then reverses the direction and repeats the
process.
D) The client folds and refolds clothing in a drawer before each meal.
Answer: A
Explanation: A) The client who watches television while eating meals and engages in
conversation with a roommate is exhibiting behavior that suggests treatment for obsessive-
compulsive disorder is effective. This behavior is evidence of reduced anxiety and less of a need
to engage in ritualistic behavior. The other observations would indicate the need for additional
treatment.
B) The client who watches television while eating meals and engages in conversation with a
roommate is exhibiting behavior that suggests treatment for obsessive-compulsive disorder is
effective. This behavior is evidence of reduced anxiety and less of a need to engage in ritualistic
behavior. The other observations would indicate the need for additional treatment.
C) The client who watches television while eating meals and engages in conversation with a
D) The client who watches television while eating meals and engages in conversation with a
Page Ref: 1938
Learning Outcome: 7. Evaluate expected outcomes for an individual with OCD.
40
7) A client was prescribed fluoxetine (Prozac) for treatment of obsessive-compulsive disorder.
During the latest office visit, the client washes the hands while counting to 10 and repeats the
process every 5 minutes. What should the nurse assess in this client?
A) The amount of medication the client is taking
B) Side effects from the medication the client is experiencing
C) Whether the client is taking the medication as prescribed
D) Foods that may be interacting with the client's medication
Answer: C
Explanation: A) Fluoxetine (Prozac) is one medication prescribed for the treatment of obsessive-
compulsive disorder. Because the client is demonstrating continuing signs of the disorder, the
nurse should assess if the client is taking the medication as prescribed. The client would have
other signs and symptoms if taking too much medication. There are no specific foods to avoid
when taking this medication. Continuing symptoms of obsessive-compulsive disorder is not a
side effect of the medication.
B) Fluoxetine (Prozac) is one medication prescribed for the treatment of obsessive-compulsive
disorder. Because the client is demonstrating continuing signs of the disorder, the nurse should
assess if the client is taking the medication as prescribed. The client would have other signs and
symptoms if taking too much medication. There are no specific foods to avoid when taking this
medication. Continuing symptoms of obsessive-compulsive disorder is not a side effect of the
medication.
C) Fluoxetine (Prozac) is one medication prescribed for the treatment of obsessive-compulsive
medication.
D) Fluoxetine (Prozac) is one medication prescribed for the treatment of obsessive-compulsive
medication.
Page Ref: 1916
care of an individual with OCD.
41
8) The intervention most appropriate for the nurse to take when working with a client with
obsessive-compulsive disorder is which of the following?
A) Confront the client and ask what purpose the behavior serves.
B) Tell the client that the behavior is unacceptable and must end.
C) Interrupt the ritualistic behavior when observed.
D) Discuss the need to incorporate the behavior with other hospital routines.
Answer: D
Explanation: A) The client with obsessive-compulsive behavior will not be able to perform the
behavior at will, so the nurse needs to discuss the need to incorporate the behavior with other
hospital routines. The nurse should not interrupt the behavior, as this will cause the client to start
over from the beginning. The nurse should also not confront the client and ask what purpose it
serves, as the client might be embarrassed about the behavior. Telling the client that the behavior
is unacceptable and must end also will not help the client with the behavior.
B) The client with obsessive-compulsive behavior will not be able to perform the behavior at
will, so the nurse needs to discuss the need to incorporate the behavior with other hospital
routines. The nurse should not interrupt the behavior, as this will cause the client to start over
from the beginning. The nurse should also not confront the client and ask what purpose it serves,
as the client might be embarrassed about the behavior. Telling the client that the behavior is
unacceptable and must end also will not help the client with the behavior.
C) The client with obsessive-compulsive behavior will not be able to perform the behavior at
D) The client with obsessive-compulsive behavior will not be able to perform the behavior at
Page Ref: 1938
Learning Outcome: 6. Plan evidence-based care for an individual with OCD and his or her
family in collaboration with other members of the healthcare team.
42
9) A client diagnosed with obsessive-compulsive disorder (OCD) is being admitted as an
inpatient. The client is obsessed with thoughts of symmetry. Which compulsive behavior(s)
could the nurse anticipate seeing during the assessment?
A) The client repeatedly washes his hands.
B) The client repeatedly taps both wrists on the bedside table.
C) The client avoids shaking the nurse's hand
D) The client begins counting the floor tiles.
E) The client repeatedly cleans the top of the bedside table.
Answer: B, D
Explanation: A) Repeatedly tapping both wrists on the bedside table and counting the floor tiles
demonstrate common behaviors of a client whose obsession is symmetry. A client whose
obsession is symmetry often demonstrates counting, ensuring orderliness of items, or fixation on
maintaining symmetrical positioning of items, such as repeatedly tapping both wrists on the
bedside table. On the other hand, a client whose obsession is cleaning typically demonstrates
repetitive performance of decontamination practices, such as repetitive hand washing; avoidance
of contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such
as repeatedly cleaning the top of the bedside table.
B) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate
common behaviors of a client whose obsession is symmetry. A client whose obsession is
symmetry often demonstrates counting, ensuring orderliness of items, or fixation on maintaining
symmetrical positioning of items, such as repeatedly tapping both wrists on the bedside table. On
the other hand, a client whose obsession is cleaning typically demonstrates repetitive
performance of decontamination practices, such as repetitive hand washing; avoidance of
contamination, such as refusing to shaking hands; or repetitive environmental cleaning, such as
repeatedly cleaning the top of the bedside table.
C) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate
D) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate
43
E) Repeatedly tapping both wrists on the bedside table and counting the floor tiles demonstrate
Page Ref: 1936
44
10) A nurse is providing discharge instructions to a client recently diagnosed with obsessive-
compulsive disorder (OCD) and prescribed Fluvoxamine (Luvox). Which statement made by the
client indicates to the nurse that the client understands the instructions?
A) "I am glad the physician chose this medication because it does not have any side effects."
B) "I should continue taking this medication and in 1-2 years I can stop taking it."
C) "I should continue taking this medication and in 1-2 years my physician may taper me off
gradually."
D) "Even though I don't think this medication is for my OCD I will take it because the physician
wants me to."
Answer: C
Explanation: A) This statement indicates that the client understands instruction regarding this
medication. A client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a
physician may begin gradually tapering, while observing the client for symptom exacerbation.
Fluvoxamine (Luvox) does have side effects; however, it has fewer side effects than
clomipramine and is recommended for the first medication trial. Fluvoxamine (Luvox) is
approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD.
B) This statement indicates that the client understands instruction regarding this medication. A
client should continue taking Fluvoxamine (Luvox) for 1-2 years, at which time a physician may
begin gradually tapering, while observing the client for symptom exacerbation. Fluvoxamine
(Luvox) does have side effects; however, it has fewer side effects than clomipramine and is
recommended for the first medication trial. Fluvoxamine (Luvox) is approved by the U.S. Food
and Drug Administration (FDA) for treatment of OCD.
C) This statement indicates that the client understands instruction regarding this medication. A
D) This statement indicates that the client understands instruction regarding this medication. A
Page Ref: 1934
care of an individual with OCD.
45
11) A nurse is evaluating the plan of care for a client diagnosed with obsessive-compulsive
disorder (OCD). Which comment made by the client would indicate to the nurse that the client
has had a positive outcome?
A) "Instead of washing my hands several times a day I use hand sanitizer several times a day."
B) "I am still hand washing frequently, and even though it is less than before I am a failure."
C) "I am still hand washing frequently but it is less often than before. I think I am improving."
D) "I don't know why I can't wash my hands several times a day; I have nothing else to do
anyway."
Answer: C
Explanation: A) The client who acknowledges improvement when washing hands less
frequently recognizes that continued obsessive-compulsive behaviors are not an indication of
treatment failure and that reductions in behavior signify positive progress. The client who has
substituted the ritualistic use of hand sanitizer for the ritualistic hand washing has not
demonstrated adequate coping skills to control anxiety related to absence of ritualistic
compulsive behaviors. The client who sees nothing wrong with washing hands several times a
day does not recognize that the ritualistic hand washing is a problem.
B) The client who acknowledges improvement when washing hands less frequently recognizes
that continued obsessive-compulsive behaviors are not an indication of treatment failure and that
reductions in behavior signify positive progress. The client who has substituted the ritualistic use
of hand sanitizer for the ritualistic hand washing has not demonstrated adequate coping skills to
control anxiety related to absence of ritualistic compulsive behaviors. The client who sees
nothing wrong with washing hands several times a day does not recognize that the ritualistic
hand washing is a problem.
C) The client who acknowledges improvement when washing hands less frequently recognizes
D) The client who acknowledges improvement when washing hands less frequently recognizes
Page Ref: 1938
Learning Outcome: 7. Evaluate expected outcomes for an individual with OCD.
46
Exemplar 31.4 Phobias
1) A client states, "I haven't left my house for 6 years." The nurse realizes the client is
experiencing which of the following?
A) Hematophobia
B) Social phobia
C) Pathophobia
D) Agoraphobia
Answer: D
Explanation: A) Agoraphobia is the fear of places or situations where the individual feels unable
to escape. Because of these fears, the individual may not leave the home. Social phobia is a fear
of social or performance situations where embarrassment may occur. Hematophobia is the fear of
blood. Pathophobia is the fear of disease.
B) Agoraphobia is the fear of places or situations where the individual feels unable to escape.
Because of these fears, the individual may not leave the home. Social phobia is a fear of social or
performance situations where embarrassment may occur. Hematophobia is the fear of blood.
Pathophobia is the fear of disease.
C) Agoraphobia is the fear of places or situations where the individual feels unable to escape.
D) Agoraphobia is the fear of places or situations where the individual feels unable to escape.
Page Ref: 1940
direct and indirect causes of phobias.
47
2) A client asks for a hospital bed near the door because of a fear of being trapped in a room and
not being able to get out. The nurse realizes this client's fear could be related to which of the
following?
A) Genetic predisposition
B) A traumatic event
C) Observing others
D) Informational transmission
Answer: B
Explanation: A) Factors that predispose an individual to develop phobias, such as the fear of not
getting out of a room, include traumatic events. Genetic predisposition would mean that others in
the client's family have the same fear. Informational transmission means the fear would be
explained or demonstrated through the media. Observing others would mean that the client has
seen others demonstrate the same fear of not being near the door.
B) Factors that predispose an individual to develop phobias, such as the fear of not getting out of
a room, include traumatic events. Genetic predisposition would mean that others in the client's
family have the same fear. Informational transmission means the fear would be explained or
demonstrated through the media. Observing others would mean that the client has seen others
demonstrate the same fear of not being near the door.
C) Factors that predispose an individual to develop phobias, such as the fear of not getting out of
D) Factors that predispose an individual to develop phobias, such as the fear of not getting out of
Page Ref: 1940
Learning Outcome: 2. Identify risk factors and prevention methods associated with phobias.
48
3) What is the role of the nurse when providing care to a client with a phobic disorder?
A) Providing comfort and alleviating emotional distress
B) Encouraging the client to confront fears
C) Providing medication to help reduce the symptoms of the disorder
D) Telling the client that the hospital is a safe place
Answer: A
Explanation: A) The role of the professional nurse caring for clients with phobic disorders is to
provide comfort to the client and family and alleviate emotional distress. The nurse supports
adaptive coping while empowering the client by providing information, accessing resources, and
communicating therapeutically. The nurse should not encourage the client to confront fears or
tell the client that the hospital is a safe place. The client may or may not be prescribed
medication for the disorder.
B) The role of the professional nurse caring for clients with phobic disorders is to provide
comfort to the client and family and alleviate emotional distress. The nurse supports adaptive
coping while empowering the client by providing information, accessing resources, and
C) The role of the professional nurse caring for clients with phobic disorders is to provide
D) The role of the professional nurse caring for clients with phobic disorders is to provide
Page Ref: 1943
the life span for individuals with phobias.
49
4) Which diagnosis would be appropriate for a client with a fear of doctors and hospitals?
A) Ineffective Health Maintenance
B) Depression
C) Anxiety
D) Ineffective Coping
Answer: A
Explanation: A) The client with a fear of doctors and hospitals might not participate in routine
healthcare activities, which could lead to ineffective health maintenance. There is not enough
information to determine whether the client is or is not experiencing ineffective coping, anxiety,
or depression.
B) The client with a fear of doctors and hospitals might not participate in routine healthcare
activities, which could lead to ineffective health maintenance. There is not enough information to
determine whether the client is or is not experiencing ineffective coping, anxiety, or depression.
C) The client with a fear of doctors and hospitals might not participate in routine healthcare
D) The client with a fear of doctors and hospitals might not participate in routine healthcare
Page Ref: 1943
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with a
phobia.
50
5) A client tells the nurse about getting short of breath and feeling dizzy every time he has to use
an elevator. What should the nurse do to assist this client?
A) Assist the client to rethink the degree of anxiety associated with elevators.
B) Ask the client how he has survived in life so far with elevators.
C) Instruct the client in deep breathing exercises.
D) Suggest that the client should avoid elevators.
E) Tell the client that elevators are completely safe.
Answer: A, C
Explanation: A) Deep breathing exercises can help the client reduce the anxiety associated with
a fearful situation, such as entering an elevator. Assisting the client to rethink the degree of
anxiety associated with elevators helps the client learn to manage the anxiety. Suggesting that the
client avoid elevators will not help the client. Asking the client how he has survived in life so far
with elevators will not help the situation. Telling the client that elevators are completely safe
might not be true and should not be said to the client.
B) Deep breathing exercises can help the client reduce the anxiety associated with a fearful
situation, such as entering an elevator. Assisting the client to rethink the degree of anxiety
associated with elevators helps the client learn to manage the anxiety. Suggesting that the client
avoid elevators will not help the client. Asking the client how he has survived in life so far with
elevators will not help the situation. Telling the client that elevators are completely safe might
not be true and should not be said to the client.
C) Deep breathing exercises can help the client reduce the anxiety associated with a fearful
D) Deep breathing exercises can help the client reduce the anxiety associated with a fearful
E) Deep breathing exercises can help the client reduce the anxiety associated with a fearful
Page Ref: 1943
Learning Outcome: 5. Plan evidence-based care for an individual with a phobia and his or her
51
6) The nurse instructing a client with social phobia knows the teaching has been effective when
the client makes which statement?
A) "I try to avoid all situations where I am expected to talk in front of other people."
B) "I can control anxiety by deep breathing and relaxing before talking in front of other people."
C) "I take an antianxiety pill before I have to do anything in front of other people."
D) "I can have a drink before I speak in front of other people."
Answer: B
Explanation: A) People with social phobias may medicate themselves with alcohol or drugs to
make it possible to endure social situations. This is not evidence that teaching has been effective.
The individual with a social phobia may also avoid all situations in which the phobia occurs.
This is also not evidence of successful instruction. Learning to control anxiety by deep breathing
and relaxation is evidence that instruction about social phobias has been successful.
B) People with social phobias may medicate themselves with alcohol or drugs to make it
possible to endure social situations. This is not evidence that teaching has been effective. The
individual with a social phobia may also avoid all situations in which the phobia occurs. This is
also not evidence of successful instruction. Learning to control anxiety by deep breathing and
relaxation is evidence that instruction about social phobias has been successful.
C) People with social phobias may medicate themselves with alcohol or drugs to make it
D) People with social phobias may medicate themselves with alcohol or drugs to make it
Page Ref: 1943
Learning Outcome: 7. Evaluate expected outcomes for an individual with a phobia.
52
7) A client wants to visit family in Asia but has a fear of flying. What is an appropriate strategy
to teach this client?
A) Cognitive restructuring
B) The use of antianxiety medication
C) Meditation
D) Physical exercise
Answer: A
Explanation: A) Cognitive restructuring is based on the belief than anxiety stems from erroneous
interpretations of situations. The client learns to reframe or relabel a frightening situation or
activity so that it becomes less threatening. Meditation helps with relaxation. The use of
antianxiety medication will not help the client learn how to cope with the anxiety associated with
flying. Physical exercise does not directly deal with cognition.
B) Cognitive restructuring is based on the belief than anxiety stems from erroneous
C) Cognitive restructuring is based on the belief than anxiety stems from erroneous
D) Cognitive restructuring is based on the belief than anxiety stems from erroneous
Page Ref: 1942
care of an individual with a phobia.
53
8) A client is experiencing severe anxiety associated with a phobia. What should the nurse do to
help this client?
A) Explain why the reaction to the phobia is unrealistic.
B) Make sure the client understands that she is safe.
C) Teach why the phobia is imagined.
D) Coach the client to deep breathe.
E) Ensure a quiet and calm environment.
Answer: B, E
Explanation: A) As a client's anxiety level associated with a phobia increases, judgment and the
ability to listen, remember, and learn are impaired. This is not the time to teach or present new
information. The nurse should not argue with the client about the perception of reality. The nurse
needs to ensure safety and offer a quiet, calm environment. Coaching in deep breathing would be
applicable after the client is stabilized.
B) As a client's anxiety level associated with a phobia increases, judgment and the ability to
listen, remember, and learn are impaired. This is not the time to teach or present new
C) As a client's anxiety level associated with a phobia increases, judgment and the ability to
D) As a client's anxiety level associated with a phobia increases, judgment and the ability to
E) As a client's anxiety level associated with a phobia increases, judgment and the ability to
Page Ref: 1943
the life span for individuals with phobias.
54
9) A nurse working on a behavioral health unit should be aware that which of the following are
examples of cognitive-behavioral therapy (CBT)?
A) Cognitive restructuring
B) Relaxation techniques
C) Systematic desensitization
D) Reciprocal inhibition
E) Benzodiazepine administration
Answer: A, C, D
Explanation: A) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are
all forms of CBT. Relaxation techniques are a nursing intervention and not a form of CBT.
Benzodiazepine administration for a short time may be beneficial but is not a form of CBT; it is a
pharmacological therapy that may be beneficial if used with CBT.
B) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of
CBT. Relaxation techniques are a nursing intervention and not a form of CBT. Benzodiazepine
administration for a short time may be beneficial but is not a form of CBT; it is a
C) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of
D) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of
E) Cognitive restructuring, systematic desensitization, and reciprocal inhibition are all forms of
Page Ref: 1942
care of an individual with a phobia.
55
10) A nursing instructor is planning a class for students on the topic of phobias. The nursing
instructor would identify which individuals as being at a highest risk for developing social
anxiety disorder?
A) 11-year-old boy
B) 14-year-old girl
C) 26-year-old female
D) 30-year-old male
E) 17-year-old male
Answer: B
Explanation: A) A 14-year-old girl would be at highest risk for developing social anxiety
disorder because social anxiety disorder (formerly known as social phobia) typically develops
between the ages of 11 and 15, and phobias are twice as likely to develop in girls and women
than in males. Social anxiety disorder almost never occurs after the age of 25.
B) A 14-year-old girl would be at highest risk for developing social anxiety disorder because
social anxiety disorder (formerly known as social phobia) typically develops between the ages of
11 and 15, and phobias are twice as likely to develop in girls and women than in males. Social
anxiety disorder almost never occurs after the age of 25.
C) A 14-year-old girl would be at highest risk for developing social anxiety disorder because
D) A 14-year-old girl would be at highest risk for developing social anxiety disorder because
E) A 14-year-old girl would be at highest risk for developing social anxiety disorder because
Page Ref: 1941
Learning Outcome: 2. Identify risk factors and prevention methods associated with phobias.
56
11) The nurse concludes that a client with agoraphobia has met an appropriate goal when the
client makes which statement?
A) "I will be able to make it to my outpatient appointments as long as I can find someone to go
with me. It is just easier if I ride with someone."
B) "I can't participate in counseling once I get discharged because I hate to leave the house if I
don't have to. Other people hate to leave their house for no reason."
C) "It is not going to be easy but I will be making it to my appointments even if I have to leave
the house by myself. I have been practicing and deep breathing exercises are helping."
D) "Every time I try to leave the house I panic and I feel like passing out. I just don't know how
this is going to get any better."
Answer: C
Explanation: A) The client who acknowledges that leaving the home alone is difficult but is
committed to keeping appointments, and indicates that deep breathing exercises are helping, is
verbalizing healthy ways of responding to the fear. The other statements indicate that the client
has not met an appropriate goal in responding to the fear.
B) The client who acknowledges that leaving the home alone is difficult but is committed to
keeping appointments, and indicates that deep breathing exercises are helping, is verbalizing
healthy ways of responding to the fear. The other statements indicate that the client has not met
an appropriate goal in responding to the fear.
C) The client who acknowledges that leaving the home alone is difficult but is committed to
D) The client who acknowledges that leaving the home alone is difficult but is committed to
Page Ref: 1943
Learning Outcome: 7. Evaluate expected outcomes for an individual with a phobia.
57
Exemplar 31.5 Posttraumatic Stress Disorder
1) During the assessment, the nurse observes a client who was a victim of a home invasion
abruptly stand up and begin to run out of the room in response to hearing a loud bang. What
should be the nurse's initial response?
A) The client thought there was an earthquake.
B) The client was reacting to the loud noise as a form of a flashback.
C) The client wanted to check the cause for the loud noise.
D) The client thought the assessment was concluded.
Answer: B
Explanation: A) Flashbacks are the recurrence of images, sounds, smells, or feelings from a
traumatic event that are triggered by daily events such as a door banging. The client's reaction to
hearing a loud bang from a door could have made the client recall being at home during the
home invasion. The client most likely did not think that the assessment was concluded or that
there was an earthquake. The client would not have abruptly begun to run out of the room if
checking for the source of the loud noise.
B) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event
that are triggered by daily events such as a door banging. The client's reaction to hearing a loud
bang from a door could have made the client recall being at home during the home invasion. The
client most likely did not think that the assessment was concluded or that there was an
earthquake. The client would not have abruptly begun to run out of the room if checking for the
source of the loud noise.
C) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event
D) Flashbacks are the recurrence of images, sounds, smells, or feelings from a traumatic event
Page Ref: 1946
direct and indirect causes of posttraumatic stress disorder (PTSD).
58
2) The nurse suspects a client is experiencing posttraumatic stress disorder when what is
assessed?
A) Observed family member be raped and murdered
B) Restores antique automobiles as a hobby
C) Lives with spouse and has a garden
D) Has a history of anxiety disorder
E) Recently terminated from employment
Answer: A, D, E
Explanation: A) Risk factors for the development of posttraumatic stress disorder include
watching others be harmed or killed, the presence of a preexisting mental illness, and the stress
associated with the loss of employment. Engaging in hobbies and living with a spouse are not
risk factors for the disorder.
B) Risk factors for the development of posttraumatic stress disorder include watching others be
harmed or killed, the presence of a preexisting mental illness, and the stress associated with the
loss of employment. Engaging in hobbies and living with a spouse are not risk factors for the
disorder.
C) Risk factors for the development of posttraumatic stress disorder include watching others be
disorder.
D) Risk factors for the development of posttraumatic stress disorder include watching others be
disorder.
E) Risk factors for the development of posttraumatic stress disorder include watching others be
disorder.
Page Ref: 1946
Learning Outcome: 2. Identify risk factors and prevention methods associated with PTSD.
59
3) A client witnessed a violent bank robbery. What would indicate to the nurse that the client is
experiencing posttraumatic stress disorder?
A) Fear of returning to sleep
B) Excessive sleeping
C) Terrifying nightmares
D) Aggressive behavior
E) Hair pulling
Answer: A, C, D
Explanation: A) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are
physical characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are
not symptoms of posttraumatic stress disorder.
B) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical
characteristics of posttraumatic stress disorder. Excessive sleeping and hair pulling are not
symptoms of posttraumatic stress disorder.
C) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical
D) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical
E) Aggressive behavior, terrifying nightmares, and fear of returning to sleep are physical
Page Ref: 1947
the life span for individuals with PTSD.
60
4) A client tells the nurse about continually reliving a situation of being robbed and shot by a
gunman. The nurse identifies the most appropriate diagnosis for this client as being which of the
following?
A) Fear
B) Anxiety
C) Post-Trauma Syndrome
D) Ineffective Coping
Answer: C
Explanation: A) The client is reliving a traumatic event and has nightmares of being shot. This
information would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might
be appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
B) The client is reliving a traumatic event and has nightmares of being shot. This information
would support the diagnosis of Post-Trauma Syndrome. The other diagnoses might be
appropriate; however, Post-Trauma Syndrome would be the priority diagnosis at this time.
C) The client is reliving a traumatic event and has nightmares of being shot. This information
D) The client is reliving a traumatic event and has nightmares of being shot. This information
Page Ref: 1948
PTSD.
61
5) What should the nurse plan for a client diagnosed with posttraumatic stress disorder who has
experienced symptoms for 4 months?
A) Guidelines on conducting activities of daily living
B) Information on the treatments available
C) Referral to local employment agency
D) Information on the need for adequate exercise
Answer: B
Explanation: A) The nurse should plan to provide the client with information on the treatments
available for posttraumatic stress disorder. Information on exercise and activities of daily living
will most likely not help the client's symptoms. Referral to the local employment agency may or
may not be necessary.
B) The nurse should plan to provide the client with information on the treatments available for
posttraumatic stress disorder. Information on exercise and activities of daily living will most
likely not help the client's symptoms. Referral to the local employment agency may or may not
be necessary.
C) The nurse should plan to provide the client with information on the treatments available for
be necessary.
D) The nurse should plan to provide the client with information on the treatments available for
be necessary.
Page Ref: 1949
Learning Outcome: 5. Plan evidence-based care for an individual with PTSD and his or her
62
6) The nurse is reviewing the effectiveness of care provided to a client diagnosed with
posttraumatic stress disorder. Which would indicate that interventions have been beneficial for
this client?
A) The client takes a sedative at least 4 times a day.
B) The client has been sleeping throughout the night.
C) The client keeps all of the lights on at home.
D) The client verbalizes future plans with family and friends.
E) The client will not enter a car with fewer than three people.
Answer: B, D
Explanation: A) Evidence of effective intervention for posttraumatic stress disorder would be
the client being able to sleep throughout the night and verbalizing future plans with family and
friends. The client who is unable to enter a car with fewer than three people, keeps all of the
lights on in the home, or takes sedatives 4 times a day is exhibiting behavior that indicates
interventions have not been successful.
B) Evidence of effective intervention for posttraumatic stress disorder would be the client being
able to sleep throughout the night and verbalizing future plans with family and friends. The client
who is unable to enter a car with fewer than three people, keeps all of the lights on in the home,
or takes sedatives 4 times a day is exhibiting behavior that indicates interventions have not been
successful.
C) Evidence of effective intervention for posttraumatic stress disorder would be the client being
successful.
D) Evidence of effective intervention for posttraumatic stress disorder would be the client being
successful.
E) Evidence of effective intervention for posttraumatic stress disorder would be the client being
successful.
Page Ref: 1949
Learning Outcome: 6. Evaluate expected outcomes for an individual with PTSD.
63
7) A client diagnosed with posttraumatic stress disorder is experiencing insomnia. Which
intervention(s) would be beneficial for this client?
A) Discuss the importance of exercise before sleep.
B) Instruct in relaxation techniques.
C) Encourage the use of sedatives.
D) Suggest daytime naps.
E) Coach in the use of guided imagery.
Answer: B, E
Explanation: A) Insomnia is a common experience in clients with posttraumatic stress disorder.
Relaxation techniques and guided imagery are just two therapies found to be beneficial in clients
with this disorder. Daytime naps are to be avoided. Sedatives do not produce long-term relief
from insomnia and should not be encouraged. Exercise before sleep would serve as a stimulant
and should not be encouraged.
B) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation
techniques and guided imagery are just two therapies found to be beneficial in clients with this
disorder. Daytime naps are to be avoided. Sedatives do not produce long-term relief from
insomnia and should not be encouraged. Exercise before sleep would serve as a stimulant and
should not be encouraged.
C) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation
D) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation
E) Insomnia is a common experience in clients with posttraumatic stress disorder. Relaxation
Page Ref: 1947
care of an individual with PTSD.
64
8) Which interventions would be appropriate for a client demonstrating acute anxiety related to
posttraumatic stress disorder?
A) Encourage the client to discuss what caused the syndrome to develop.
B) Provide a calm, quiet environment.
C) Give the client paperwork to complete while waiting to be assessed.
D) Ask the client what is causing the anxiety.
E) Reassure the client that the environment is safe.
Answer: B, E
Explanation: A) The client diagnosed with post-traumatic stress disorder who is exhibiting
extreme anxiety needs immediate pharmacologic intervention, a quiet and calm environment,
and reassurance of his or her safety. The client should not be given paperwork to complete.
Asking the client what is causing the anxiety and encouraging the client to discuss what caused
the syndrome to develop are not effective interventions for acute anxiety related to this disorder
and should not be done.
B) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety
needs immediate pharmacologic intervention, a quiet and calm environment, and reassurance of
his or her safety. The client should not be given paperwork to complete. Asking the client what is
causing the anxiety and encouraging the client to discuss what caused the syndrome to develop
are not effective interventions for acute anxiety related to this disorder and should not be done.
C) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety
D) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety
E) The client diagnosed with post-traumatic stress disorder who is exhibiting extreme anxiety
Page Ref: 1948
65
9) A client is being admitted with a diagnosis of post-traumatic stress disorder (PTSD). During a
review of the client's history, the nurse is made aware that the client suffers from depression and
suicidal thoughts. While interviewing the client, the client tells the nurse he is feeling extremely
irritable and that the main reason he is there is because he has been having frequent nightmares.
Based on the assessment findings, the nurse anticipates the physician will order which
medication?
A) Propanolol (Inderal)
B) Prazosin (Minipress)
C) Risperidone (Risperdal)
D) Fluvoxamine (Luvox)
Answer: B
Explanation: A) Prazosin is an antihypertensive medication that may be prescribed for treatment
and prevention of nightmares. Propanolol (Inderal) is a beta-blocker; its possible uses include
management of anxiety states and prevention of acute panic states. Risperidone (Risperdal) is an
antipsychotic that may be used in the treatment of OCD or panic disorders. Fluvoxamine
(Luvox) is a selective serotonin reuptake inhibitor (SSRI) that may be used in the treatment of
OCD.
B) Prazosin is an antihypertensive medication that may be prescribed for treatment and
prevention of nightmares. Propanolol (Inderal) is a beta-blocker; its possible uses include
OCD.
C) Prazosin is an antihypertensive medication that may be prescribed for treatment and
OCD.
D) Prazosin is an antihypertensive medication that may be prescribed for treatment and
OCD.
Page Ref: 1947
care of an individual with PTSD.
66
10) A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder
(PTSD). The client was recently admitted to the hospital for suicide ideation and a sleep
disturbance due to frequent nightmares. Which goal will the nurse identify as the priority goal for
this client?
A) The client will report a reduction in or cessation of nightmares.
B) The client will report a decreased perception of anxiety.
C) The client will discuss emotions related to traumatic experiences.
D) The client will remain free from injury or harm.
Answer: D
Explanation: A) Assuring that the client remains free of injury would be the priority goal. The
client was admitted with thoughts of suicide, and this places the client at risk for harm or self-
injury. Safety is a priority. The other goals are relevant to the care of the client; however, they
are not the priority goals.
B) Assuring that the client remains free of injury would be the priority goal. The client was
admitted with thoughts of suicide, and this places the client at risk for harm or self-injury. Safety
is a priority. The other goals are relevant to the care of the client; however, they are not the
priority goals.
C) Assuring that the client remains free of injury would be the priority goal. The client was
priority goals.
D) Assuring that the client remains free of injury would be the priority goal. The client was
priority goals.
Page Ref: 1949
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
67
11) A nurse is developing a plan of care for a client diagnosed with post-traumatic stress disorder
(PTSD). The client was recently admitted to the hospital for suicide ideation and a sleep
disturbance due to frequent nightmares. Which nursing diagnosis will the nurse identify as the
priority nursing diagnosis for this client?
A) Disturbed Sleep Pattern
B) Post-Trauma Syndrome
C) Risk for Other-Directed Violence
D) Risk for Self-Directed Violence
Answer: D
Explanation: A) Because the client is experiencing thoughts of suicide, Risk for Self-Directed
Violence would be the priority nursing diagnosis. Although the client reports sleep disturbances
related to frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing
diagnosis. Post-Trauma Syndrome may be appropriate for this client; however, it would not be
the priority nursing diagnosis. There is no indication in the findings that the client is at risk for
injuring or harming others; therefore Risk for Other-Directed Violence would not be appropriate
for this client.
B) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would
be the priority nursing diagnosis. Although the client reports sleep disturbances related to
frequent nightmares, Disturbed Sleep Pattern would not be the priority nursing diagnosis. Post-
Trauma Syndrome may be appropriate for this client; however, it would not be the priority
nursing diagnosis. There is no indication in the findings that the client is at risk for injuring or
harming others; therefore Risk for Other-Directed Violence would not be appropriate for this
client.
C) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would
client.
D) Because the client is experiencing thoughts of suicide, Risk for Self-Directed Violence would
client.
Page Ref: 1948
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
PTSD.
68

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Module 31 Stress and Coping

The Concept of Stress and Coping

1) The nurse is concerned that a client is demonstrating signs of obsessive-compulsive disorder

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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

Module 31 Stress and Coping

The Concept of Stress and Coping

1) The nurse is concerned that a client is demonstrating signs of obsessive-compulsive disorder

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M31 Stress & Coping

M31 Stress & Coping

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