Key Takeaways
- Anxiety exists on a continuum from mild (enhanced learning and problem-solving) to panic (complete loss of control and inability to function)
- During a panic attack, stay with the client, maintain a calm demeanor, and use short, simple sentences
- Generalized Anxiety Disorder (GAD) involves excessive worry occurring more days than not for at least 6 months
- Phobias involve intense, irrational fear of specific objects or situations that leads to avoidance behaviors
- Obsessive-Compulsive Disorder (OCD) involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions) performed to reduce anxiety
Anxiety Disorders and Mental Health Concepts
Anxiety is a universal human experience, but when it becomes excessive or interferes with daily functioning, it crosses into the realm of mental health disorders. The NCLEX tests your understanding of anxiety levels, common anxiety disorders, and appropriate nursing interventions.
The Four Levels of Anxiety
Anxiety exists on a continuum from mild to panic. Each level has distinct characteristics and requires different nursing approaches.
| Level | Characteristics | Learning Ability | Nursing Focus |
|---|---|---|---|
| Mild | Alert, slight tension, enhanced perception | Optimal | Use for teaching |
| Moderate | Narrowed perception, selective attention | Decreased | Redirect, structure |
| Severe | Greatly reduced perception, difficulty thinking | Significantly impaired | Safety, simple tasks |
| Panic | Complete loss of control, terror | Impossible | Stay present, safety |
Mild Anxiety
Mild anxiety is adaptive and actually enhances performance.
Characteristics:
- Alert and attentive
- Perceptual field is broad
- Motivation increased
- Slight restlessness
- Heightened awareness
Nursing considerations:
- Optimal time for teaching
- Learning is enhanced
- Problem-solving improved
- No intervention needed unless it escalates
Moderate Anxiety
Moderate anxiety begins to narrow the perceptual field.
Characteristics:
- Selective inattention (focuses on immediate concern)
- Voice changes (may tremble or increase in pitch)
- Physical symptoms (increased heart rate, sweating)
- Sees, hears, and grasps less
- Can be redirected with assistance
Nursing interventions:
- Use therapeutic communication
- Help client focus on the present
- Break tasks into smaller steps
- Provide structure
- Encourage relaxation techniques
Severe Anxiety
Severe anxiety significantly impairs functioning.
Characteristics:
- Greatly reduced perceptual field
- Difficulty thinking clearly
- Focus on small or scattered details
- Physical symptoms intensify
- Communication may become scattered
- Unable to problem-solve
Nursing interventions:
- Reduce stimuli in the environment
- Stay with the client
- Use simple, direct statements
- Do NOT teach at this level
- Focus on safety
- Provide one task at a time
Panic-Level Anxiety
Panic represents a complete loss of control and is a psychiatric emergency.
Characteristics:
- Terror, dread, feeling of impending doom
- Inability to communicate coherently
- Physical symptoms at maximum (palpitations, chest pain, dyspnea)
- May experience depersonalization/derealization
- Unable to function
- May be immobilized or hyperactive
Nursing interventions for panic:
- Stay with the client - Never leave someone in panic alone
- Maintain calm demeanor - Your calmness is contagious
- Use short, simple sentences - "You are safe. I am here with you."
- Move to a quiet area - Reduce environmental stimuli
- Encourage slow breathing - "Breathe with me. In... Out..."
- Do not touch without permission - Touch may increase panic
- Safety is priority - Prevent injury during crisis
Post-panic: Once the panic subsides, explore triggers and develop coping strategies.
Common Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Definition: Excessive, uncontrollable worry about multiple aspects of life occurring more days than not for at least 6 months.
Symptoms:
- Restlessness or feeling "on edge"
- Easy fatigability
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
Nursing considerations:
- Teach relaxation techniques
- Encourage regular exercise
- Limit caffeine intake
- Medications: SSRIs, SNRIs, Buspirone
Panic Disorder
Definition: Recurrent, unexpected panic attacks with persistent concern about future attacks.
Characteristics of a panic attack:
- Sudden onset of intense fear
- Peaks within minutes
- Physical symptoms: palpitations, sweating, trembling, shortness of breath, chest pain
- Fear of dying or "going crazy"
- Duration: typically 10-30 minutes
Nursing priority: During an attack, stay present and help the client feel safe.
Phobias
Definition: Intense, irrational fear of specific objects, situations, or activities that leads to avoidance.
| Type | Fear Of | Examples |
|---|---|---|
| Specific phobia | Objects/situations | Spiders, heights, blood |
| Social phobia | Social situations | Public speaking, eating in public |
| Agoraphobia | Places of escape difficulty | Crowds, open spaces, public transit |
Treatment:
- Systematic desensitization (gradual exposure)
- Cognitive-behavioral therapy
- Medications may be adjunctive
Obsessive-Compulsive Disorder (OCD)
Obsessions: Intrusive, unwanted thoughts, images, or urges that cause marked anxiety.
Compulsions: Repetitive behaviors or mental acts performed to reduce anxiety caused by obsessions.
Common themes:
| Obsession | Related Compulsion |
|---|---|
| Contamination fears | Excessive handwashing |
| Doubt ("Did I lock the door?") | Repeated checking |
| Need for symmetry | Arranging, counting |
| Forbidden thoughts | Mental rituals, praying |
Nursing considerations:
- Do NOT interrupt rituals abruptly (increases anxiety)
- Set limits gradually
- Allow extra time for daily activities
- Treatment: ERP (Exposure and Response Prevention), SSRIs
Post-Traumatic Stress Disorder (PTSD)
Definition: Develops after exposure to a traumatic event involving actual or threatened death, serious injury, or sexual violence.
Symptom clusters:
- Intrusion - Flashbacks, nightmares, intrusive memories
- Avoidance - Avoiding reminders of the trauma
- Negative changes in mood/cognition - Blame, detachment, negative beliefs
- Hyperarousal - Hypervigilance, startle response, sleep problems
Nursing considerations:
- Create a safe, trusting environment
- Avoid retraumatization
- Trauma-informed care approach
- Treatment: Trauma-focused CBT, EMDR, medications
Defense Mechanisms
Clients use defense mechanisms unconsciously to protect themselves from anxiety. Common mechanisms tested on NCLEX:
| Mechanism | Definition | Example |
|---|---|---|
| Denial | Refusing to accept reality | Cancer patient says "There must be a mistake" |
| Projection | Attributing own feelings to others | "You're the one who's angry, not me!" |
| Displacement | Redirecting emotions to safer target | Yelling at spouse after conflict with boss |
| Rationalization | Making excuses to justify behavior | "I failed because the test was unfair" |
| Regression | Returning to earlier developmental stage | Adult sucking thumb during stress |
| Repression | Unconsciously blocking painful memories | Cannot remember childhood abuse |
| Sublimation | Channeling impulses into acceptable activities | Anger channeled into sports (healthy) |
Medications for Anxiety
| Drug Class | Examples | Key Points |
|---|---|---|
| SSRIs | Sertraline, Paroxetine, Escitalopram | First-line for most anxiety disorders; 2-4 weeks for effect |
| SNRIs | Venlafaxine, Duloxetine | Also first-line; monitor blood pressure |
| Benzodiazepines | Lorazepam, Alprazolam, Diazepam | Short-term only; dependence risk; avoid abrupt discontinuation |
| Buspirone | Buspar | Non-sedating; no dependence; takes 2-4 weeks |
| Beta-blockers | Propranolol | Performance anxiety; blocks physical symptoms |
Benzodiazepine safety: Monitor for sedation, respiratory depression, falls. Flumazenil reverses overdose.
On the Exam
Key points for NCLEX questions:
- Mild anxiety = best time to teach
- Panic = stay with client, simple sentences, safety first
- Don't interrupt OCD rituals abruptly
- Phobias = systematic desensitization
- Defense mechanisms are unconscious
A client experiencing a panic attack is hyperventilating and saying, "I'm going to die!" What is the nurse's priority action?
A client with OCD spends 2 hours each morning washing their hands. What is the most appropriate nursing intervention?
At which level of anxiety is a client able to learn best?