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NCLEX & CGFNS Practice Questions
NURSING DIAGNOSIS:
Anxiety
  • Actual

Related To: [Check those that apply]

  • Threat or perceived threat to physical and emotional integrity
  • Changes in role function
  • Intrusive diagnostic and surgical tests and procedures
  • Changes in environment and routines
  • Threat or perceived threat to self-concept
  • Threat to (or change in) socioeconomic status
  • Situational and maturational crises
  • Interpersonal conflicts

As evidenced by: [Check those that apply]
Physiological

  • Increase in blood pressure, pulse, and respirations
  • Dizziness, light-headedness
  • Perspiration
  • Frequent urination
  • Flushing
  • Dyspnoea

Behavioural

  • Expressions of helplessness
  • Feelings of inadequacy
  • Crying
  • Difficulty concentrating
  • Rumination
  • Inability to problem-solve




Patient’s Diagnosis: –
Date:-
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Objective/Expected Outcome;The patient will:

  • Be able to recognize signs of anxiety.
  • Demonstrates positive coping mechanisms.
  • Describe a reduction in the level of anxiety experienced.
  • Others




Nursing Interventions Scientific Rationale
Assess patient's level of anxiety. To serve as a baseline data to compare subsequent assessment.
Determine how patient copes with anxiety. This assessment helps determine the effectiveness of coping strategies currently used by patient.
Acknowledge awareness of patient's anxiety. Acknowledgment of the patient's feelings validates the feelings and communicates acceptance of those feelings.
Reassure patient that he or she is safe. Stay with patient if this appears necessary. The presence of a trusted person may be helpful during an anxiety attack
Maintain a calm manner while interacting with patient. The health care provider can transmit his or her own anxiety to the hypersensitive patient. The patient's feeling of stability increases in a calm and nonthreatening atmosphere.
Establish a working relationship with the patient through continuity of care. An ongoing relationship establishes a basis for comfort in communicating anxious feelings.
Orient patient to the environment and new experiences or people as needed. Orientation and awareness of the surroundings promotes comfort and may decrease anxiety.
Reduce sensory stimuli by maintaining a quiet environment; keep threatening" equipment out of sight." Anxiety may escalate with excessive conversation, noise, and equipment around the patient.
Encourage patient to seek assistance from an understanding significant other or from the health care provider when anxious feelings become difficult. The presence of significant others reinforces feelings of security for the patient.
Assist the patient in developing anxiety-reducing skills (relaxation, deep breathing, positive visualization, reassuring self-statements, and others). Using anxiety-reduction strategies enhances patient's sense of personal mastery and confidence.
Assist patient in developing problem-solving abilities. Emphasize the logical strategies patient can use when experiencing anxious feelings. Learning to identify a problem and evaluate alternatives to resolve it helps patient to cope.
Assist patient in recognizing symptoms of increasing anxiety; explore alternatives to use to prevent the anxiety from immobilizing her or him. The ability to recognize anxiety symptoms at lower-intensity levels enables the patient to intervene more quickly to manage his or her anxiety.

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