Situation: T. is the nurse-manager of an oncology unit on the 18th floor of a large urban medical center. Recently, she has been increasingly afraid of riding in the elevator. This morning, she experienced shortness of breath, palpitations, dizziness, and trembling while in the elevator. T. was examined by an emergency department physician, who could find no physiologic basis for her symptoms.
1. Based on the above findings, T. is most likely suffering from:
a) dissociative disorder
b) phobic disorder
c) obsessive-compulsive disorder
d) somatization disorder
2. T. begins outpatient counseling sessions with a psychiatric clinical nurse specialist. Which nursing intervention would be most helpful in reducing T.'s anxiety level?
a) psychoanalytically oriented psychotherapy
b) group psychotherapy
c) systematic desensitization
d) referral for evaluation for electroconvulsive therapy
3. An anxious patient like T. also may benefit greatly from:
a) muscle relaxation
b) psychodrama
c) confrontation
d) biofeedback
4. Because of the severity of T.'s anxiety, the nurse refers her to a psychiatrist for medication evaluation. Which psychotropic drug regimen is most likely to prescribed on a short-term basis?
a) diazepam (valium) 5 mg orally three times a day
b) benztropine mesylate ( cogentin) 2 mg orally twice a day
c) chlorpromazine hydrochloride ( thorazine) 25 mg orally three times a day
d) thioridazine hydrochloride ( mellaril) 100 mg orally four times a day
Situation: B., age 45, is admitted to a psychiatric inpatient unit for treatment of severe obsessive-compulsive disorder.
5. B. has a compulsive bedtime ritual that includes making and remaking his bed 26 times before he can retire. Occasionally, he does not get to bed until 3:00 a.m. Which nursing intervention is most helpful?
a) discussing the ridiculousness of his repetitive behavior
b) taking turns making and remaking the bed with B. to conserve his energy and allow him to retire sooner
c) prohibiting B. from carrying out his bedtime ritual
d) suggesting that he begin his ritual earlier in the evening so he can retire by 11:30 pm
6. Besides performing his nightmare ritual. B. has recently begun a morning bed-making ritual. To help B. limit and potentially alter this maladaptive behavior, all of the following nursing interventions are therapeutic except:
a) having B. engage in constructive activities that leave less time for compulsive behaviors
b) verbalizing tactful, mild disapproval of his behavior
c) providing positive reinforcement of nonritualistic behavior
d) offering reflective feedback, such as "I see you have remade your bed many times. You must be exhausted"
7. The nurse must recognize that obsessive-compulsive rituals are an attemp to:
a) increase self-esteem
b) control others
c) express anxiety
d) avoid severe anxiety
8. An appropriately stated short-term goal for this patient is that after 1 week, B. will:
a) demonstrate decreased anxiety
b) participate in daily exercise group
c) identify the underlying reasons for his rituals
d) state that his activities is irrational
9. The psychiatrist order lorazepam (ativan) 1 mg orally three times a day. While B. is taking this medication, the nurse should remind him to:
a) avoid caffeine
b) avoid aged cheese
c) stay out of the sun
d) maintain an adequate salt intake
ANSWERS AND RATIONALE
1) B
- a phobic disorder is characterized by a persistent fear of some object or situation that presents no real danger or that magnifies the danger out of proportion. An example of this disorder is T.'s fear of riding in the elevator. A dissociative disorder occurs when a patient blocks off from consciousness some aspect of his life because of the threat of overwhelming anxiety. Amnesia is an example of dissociative disorder. An obsessive-compulsive disorder is manifested by repetitive thoughts or recurring impulses to perform certain acts -- for example, frequent hand washing. A somatization disorder occurs when a patient experiences some physical dysfunctioning resulting from profound anxiety over a repressed drive, such as the sexual drive. An example of this disorder is that of a patient who experiences blindness after becoming aroused by accidentally seeing his sister in the shower.
2) C
- phobias commonly are viewed as learned responses to anxiety that can be unlearned through certain techniques, such as behavior modification. Systemic desensitization, a form of behavior modification, attempts to reduce anxiety and thereby eradicate the patient's phobia through gradual exposure to anxiety producing stimuli. For example, a patient who is afraid of flying could be desensitized by first viewing pictures of airplanes, then going to the airport, and later just sitting in a plane before attempting to fly. Psychoanalytically oriented therapy also may be effective in this situation because recall of childhood experiences can help the patient clarify and understand her phobia. However, such therapy requires years of treatment. Group psychotherapy, which involves treating patients in groups, could be used as an adjunct treatment to help increase the patient's self-esteem and lower her generalized anxiety. Electroconvulsive therapy, the use of electric current to produce a convulsive seizure, is primarily reserved for patients with severe depression or psychosis who have responded poorly to other treatments. It usually is not indicated for phobic disorders.
3) A
- muscle relaxation techniques -- the systematic tensing and relaxing of major muscle groups -- decrease anxiety and relax thee body. They are an important adjunct to systematic desensitization. Psychodrama is the dramatization of a patient's interactions and problems. Confrontation involves calling attention to discrepancies, such as the inconsistency between a patient's affect and his verbal expressions. Psychodrama and confrontational approaches are primarily used to resolve interpersonal issues. Biofeedback attempts to bringg certain autonomic functions, such as heart rate and blood pressure, under voluntarily control. Biofeedback training is more useful for reducing stress associated with physiologically based disorders, such as hypertension, asthma, and gastritis.
4) A
- diazepam (valium) is the most appropriate medication for this patient because of its antianxiety properties. Benztropine mesylate (cogentin) is an antiparkinsonian agent used to control the extrapyramidal side effects of such antipsychotic medications as chlorpromazine hydrochloride (thorazine) and thioridazine hydrochloride (mellaril). Chlorpromazine and thioridazine are used to control the severe symptoms (hallucinations, thought disorders, agitation) seen in patients with psychosis.
5) D
- at present, B. needs this behavioral pattern to keep his anxiety within tolerable bounds. Suggesting that he begin the ritual during free time in the evening sets some limits but allows him to continue performing the behavior. Patients such as B. usually are aware of irrationality of their actions yet feel unable to stop them. Helping with the ritual is nontherapeutic reinforcement of the behavior. Attempting to prevent B. from performing his ritual would increase his anxiety and possibly precipitate panic.
6) B
- verbalizing even minimal disapproval of B.'s behavior would increase his anxiety and consequently reinforce his need to perform the rituals. Engaging B. in constructive activity provides an outlet for his energy without channeling it into compulsive behavior. Providing positive reinforcement on nonritualistic behavior trends to strengthen these constructive activities. Reflective feedback lets B. know that the nurse recognizes the behavior and understands how tiring it can be.
7) D
- obsessive-compulsive rituals are an attempt to avoid increasing anxiety to a severe level. Although the patient may feel the need to increase his self-esteem, this is not the primary reason for performing obsessive-compulsive rituals. the patient is not attempting to control others because he is anxious and preoccupied with his own behaviors. The patient's ritualistic behavior is not a means of expressing anxiety but a way to avoid it.
8) B
- participating in a daily group refocuses the patient's time toward adaptive activities and may reduce anxiety. "Demonstrate decreased anxiety" is not stated specifically enough to allow for evaluation. For this goal to be measurable, specific objectives must be stated, such as that B. will verbalize he is feeling less anxious. Insight into the underlying reasons for the rituals takes time to develop and is not a realistic goal after 1 week. A patient with an obsessive-compulsive disorder typically is well aware of the irrationality of the ritual but is unable to stop it.
9) A
- ingesting 500 mg or more of caffeine can significantly alter the anxiolytic effects of lorazepam. Other dietary restrictions are unnecessary. Aged cheeses must be avoided when taking monamine oxidase (MAO) inhibitors. Staying out of the sun or using sunscreens is required when taking phenothiazines. An adequate salt intake is necessary for patient receiving lithium.
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