Exam 2 (Ch 11-20): Mental Health: Text Review and Evolve NCLEX

A child diagnosed with ADHD is reprimanded for taking the nurse's pen without asking first. He reponds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding, a. "I do like you, but I don't like it when you grab my pen." b. "Liking you has nothing to do with whether I will loan you my pen." c. "It sounds as though you are feeling helpless and insecure." d. "You must ask for permission before taking someone else's things."

a. "I do like you, but I don't like it when you grab my pen."

Which statement is least likely to be made by a client diagnosed with bulimia nervosa during the assessment interview? a. "I eat three meals each day and purge every evening." b. "I'm concerned about what others think about my binging and purging." c. "I feel as though my eating and purging are out of my control." d. "When I eat I feel calm, but then I realize I have to make myself vomit or gain weight."

a. "I eat three meals each day and purge every evening."

Which statement by Kyla, a patient you are educating in the sleep disorders clinic, indicates that she needs further teaching? a. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." b. "Getting less than 6 hours of sleep at night may increase my risk for medical problems." c. "Getting enough sleep will increase my productivity at work." d. "Since I have to drive for my job, getting enough sleep will help me avoid accidents."

a. "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can."

One criterion for the diagnosis of primary insomnia is met when the client reports a. "I've actually missed work because I'm too tired to go." b. "I was diagnosed with depression 2 months ago." c. "I've had problems falling asleep for 3 weeks now." d. "I have these terrible nightmares when I fall asleep."

a. "I've actually missed work because I'm too tired to go."

When discussing the symptoms of PTSD, the nurse correctly states a. "The symptoms can occur almost immediately or can take years to manifest." b. "PTSD causes agitation and hypervigilance but rarely chronic depression." c. "When experiencing a flashback, the client generally experiences a slowing of responses." d. "PTSD is an emotional response that does not cause significant changes in brain chemistry."

a. "The symptoms can occur almost immediately or can take years to manifest."

A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." A helpful response for the nurse to make would be a. "What things have you done in the past that helped you feel more comfortable?" b. "Let's try to focus on that adorable little granddaughter of yours." c. "Why don't you sit down over there and work on that jigsaw puzzle?" d. "Try not to think about the feelings and sensations you're experiencing."

a. "What things have you done in the past that helped you feel more comfortable?"

Which of the following would be assessed as a negative symptom of schizophrenia? a. Anhedonia b. Hostility c. Agitation d. Hallucinations

a. Anhedonia

A young, newly married man with schizophrenia presents in the emergency department with a complaint of "demons sticking needles in my penis." Which initial response by the triage nurse would be appropriate? a. Arrange for the patient to be evaluated by the doctor or advanced practice registered nurse on duty because the patient may be expressing real pain in a delusional manner. b. Request an order for labs to rule out a sexually transmitted disease, given that the patient has recently begun sexual relations with his new wife and may have been exposed. c. Complete the triage process, and refer the patient for a mental health evaluation, since he appears to be psychotic and possibly having a relapse. d. Make the patient feel safe by telling him that it is not possible for demons to be in the emergency room.

a. Arrange for the patient to be evaluated by the doctor or advanced practice registered nurse on duty because the patient may be expressing real pain in a delusional manner.

The nurse is preparing to assess a child who primarily speaks Spanish but is fluent in English. Which is the appropriate method for gathering information? a. Begin the assessment in English b. Utilize a Spanish dictionary to ask questions to the child c. Ask the child if he understands English d. Obtain an interpreter who is fluent in Spanish

a. Begin the assessment in English

Kyle, a 23-year-old patient with schizophrenia, has been admitted to the psychiatric unit for one week. He has begun to take first-generation antipsychotic haloperidol (Haldol). One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to turn to you or respond verbally. You obtain vital signs, which are as follows: BP 170/100, P 110, T 103. What are the priority nursing interventions? Select all that apply. a. Begin to wipe him with a washcloth wet with cold water or alcohol b. Hold his medication, and contact his provider stat c. Administer a medication such as benztropine IM to correct his dystonic reaction d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass e. Explain that he has anticholinergic toxicity, hold his meds, and give IM phyostigmine f. Hold his medication tonight, and consult his provider after completing medication rounds

a. Begin to wipe him with a washcloth wet with cold water or alcohol b. Hold his medication, and contact his provider stat

A possible outcome criterion for a client diagnosed with anxiety disorder is a. Client demonstrates effective coping strategies. b. Client reports reduced hallucinations. c. Client reports feelings of tension and fatigue. d. Client demonstrates persistent avoidance behaviors.

a. Client demonstrates effective coping strategies.

Both parents of a 6-year-old are hospitalized because of a car accident. Which of the following demonstrates that the child is resilient? a. Cuddling with his grandfather while being read a bedtime story. b. Drawing his parents get-well cards. c. Telling his day care teacher that he will be a big boy and not cry. d. Asking when his parents will be home.

a. Cuddling with his grandfather while being read a bedtime story.

What information should the nurse give to the family of a client who has had a dissociative episode? a. Dissociation is a method for coping with severe stress. b. Dissociation suggests the possibility of early dementia. c. Brief periods of psychotic behavior may occur. d. Ways to intervene to prevent self-mutilation and suicide attempts.

a. Dissociation is a method for coping with severe stress.

Which of the following describe the symptoms of the manic phase of bipolar disorder? (select all that apply): a. Excessive energy b. Fatigue and increased sleep c. Low self-esteem d. Pressured speech e. Purposeless movement f. Racing thoughts g. Withdrawal from environment h. Distractibility

a. Excessive energy d. Pressured speech e. Purposeless movement f. Racing thoughts h. Distractibility

Which side effects of lithium can be expected at therapeutic levels? a. Fine hand tremor and polyuria b. Nausea and thirst c. Coarse hand tremor and gastrointestinal upset d. Ataxia and hypotension

a. Fine hand tremor and polyuria

Which behavior would be most characteristic of a client during a manic episode? a. Going rapidly from one activity to another b. Taking frequent rest periods and naps during the day c. Being unwilling to leave home to see other people d. Watching others intently and talking little

a. Going rapidly from one activity to another

The symptoms of an adjustment disorder can include (Select all that apply.) a. Guilt b. Social withdrawal c. Overachieving d. Anger e. Depression

a. Guilt b. Social withdrawal d. Anger e. Depression

Brittany is caring for a patient with bulimia. She recognizes which of the following nursing interventions as being most appropriate? a. Monitor the patient on bathroom trips after eating. b. Allow the patient extensive private time with family members. c. Provide meals whenever the patient requests them. d. Encourage the patient to select foods that she likes.

a. Monitor the patient on bathroom trips after eating.

Nick, a construction worker, is on duty when a nearly completed wall suddenly falls, crushing a number of co-workers. Although badly shaken initially, he seemed to be coping well. About two weeks after the tragedy he begins to experience tremors, nightmares, and periods during which he feels numb or detached from his environment. He finds himself frequently thinking about the tragedy and feeling guilty that he was spared while many others died. Which statement about this situation is most accurate? a. Nick has acute stress disorder and will benefit from antianxiety medications b. Nick is experiencing posttraumatic stress disorder (PTSD) and should be referred for outpatient treatment c. Nick is experiencing anxiety and grief and should be monitored for PTSD symptoms d. Nick is experiencing mild anxiety and a normal grief reaction; no intervention is needed

a. Nick has acute stress disorder and will benefit from antianxiety medications

Which of the following statements are correct regarding obsessive-compulsive disorder (OCD)? Select all that apply. a. Obsessions are repetitive thoughts, whereas compulsions are ritualistic behaviors. b. OCD symptoms can start as early as 3 years of age c. OCD patients often have difficulty sleeping. d. Schizophrenia often occurs comorbidly with OCD e. There is a tool (scale) to measure compulsive behaviors f. Patients diagnosed with OCD are at higher risk for suicide than patients with depression.

a. Obsessions are repetitive thoughts, whereas compulsions are ritualistic behaviors. b. OCD symptoms can start as early as 3 years of age c. OCD patients often have difficulty sleeping. e. There is a tool (scale) to measure compulsive behaviors

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? a. Onset of action is from 1 to 6 weeks. b. They tend to be more effective for men. c. Recent memory impairment is commonly observed. d. They often cause the client to have diurnal variation.

a. Onset of action is from 1 to 6 weeks.

Which of the following statements is true of bulimia? a. Patients with bulimia often appear at a normal weight. b. Patients with bulimia binge eat but do not engage in compensatory measures. c. Patients with bulimia severely restrict their food intake. d. One sign of bulimia is lanugo.

a. Patients with bulimia often appear at a normal weight.

A medication teaching plan for a patient receiving lithium should include: a. Periodic monitoring of renal and thyroid function b. Dietary teaching to restrict daily sodium intake c. The importance of blood draws to monitor serum potassium level d. Discontinuing the drug if weight gain and fine hand tremors are noticed.

a. Periodic monitoring of renal and thyroid function

Michael seems to be angry when his family fails to visit him in the hospital as promised. However, he tells you that he is fine and that the visit wasn't important to him. When you suggest that perhaps he might be disappointed or even a little angry that the family has again let him down, the patient responds that it is his family that is angry, not him, or else they would have visited. What defense mechanism(s) is this patient using to deal with his feelings? Select all that apply a. Rationalization b. Projection c. Regression d. Denial e. Dissociation

a. Rationalization b. Projection d. Denial

Which factor can reduce the vulnerability of a child to etiological influences predisposing to the development of psychopathology? a. Resilience b. Malnutrition c. Child abuse d. Having a depressed parent

a. Resilience

The nurse has developed a plan for a client with a severe sleep pattern disturbance to spend 20 minutes in the gym exercising each afternoon. Which intervention should be scheduled for upon returning to the unit? a. Rest b. Group therapy c. A protein-based snack d. Unstructured private time

a. Rest

Shane, aged 23 years, is admitted to your medical-surgical unit with complaints of abdominal pain, dizziness, and headaches. Results of a physical workup have been negative so far. Today Shane tells you, "Now I am having back pain." Which of the following in Shane's medical record may alert you to the possibility of malingering? (select all that apply): a. Shane has a court date this week for drunk driving. Correct b. Shane was adopted at the age of 5 years. c. Shane has a history of physical abuse by his stepfather. Correct d. Shane has a history of oppositional-defiant disorder. e. Shane was raised primarily by his mother.

a. Shane has a court date this week for drunk driving. c. Shane has a history of physical abuse by his stepfather.

Julia, a 28-year-old diagnosed with schizophrenia, is encouraged to attend groups but stays in her room instead. Staff and peers encourage her participation, but without success. Her hygiene is poor despite encouragement to shower and brush her teeth. She does not seem concerned that others wish she would behave differently. Which is the most likely explanation for Julia's failure to respond to others' efforts to help her behave in a more adaptive fashion? Select all that apply. a. She is displaying avolition b. She is experiencing anergia c. She is experiencing negativism d. She is exhibiting paranoid delusions e. She is being resistant or oppositional f. She is apathetic due to her schizophrenia

a. She is displaying avolition b. She is experiencing anergia f. She is apathetic due to her schizophrenia

The nurse is planning care for a patient with a binge eating disorder. What outcomes are appropriate? Select all that apply. a. The patient will identify stressors that lead to binge eating. b. The patient will identify four alternate coping skills c. The patient will increase dietary intake d. The patient will experience satisfaction in eating alone

a. The patient will identify stressors that lead to binge eating. b. The patient will identify four alternate coping skills

A major principle the nurse should observe when communicating with a patient experiencing elated mood is to: a. Use a calm, firm approach b. Give expanded explanations c. Make use of abstract concepts d. Encourage lightheartedness and joking

a. Use a calm, firm approach

Which item of data routinely gathered during assessment of a client with dissociative disorder would be of least relevance to planning? a. Voluntary control of symptoms b. Ability to remember c. Level of anxiety d. Evidence of disorientation

a. Voluntary control of symptoms

What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? a. Withhold medication and notify the physician. b. Continue to administer medication as ordered. c. Advise the client to limit fluids for 12 hours. d. Advise the client to curtail salt intake for 24 hours.

a. Withhold medication and notify the physician.

The causation of schizophrenia is currently understood to be a. a combination of inherited and non-genetic factors. b. deficient amounts of the neurotransmitter dopamine. c. excessive amounts of the neurotransmitter serotonin. d. stress related and ineffective stress management skills.

a. a combination of inherited and non-genetic factors.

A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as a. a neologism. b. clang association. c. blocking. d. a delusion.

a. a neologism.

The most effective nursing intervention regarding the accurate assessment of sleep disorders involves a. a sleep diary. b. information regarding sleep cycles. c. client description of the symptomatology. d. assessment for substance abuse.

a. a sleep diary.

The family of a child diagnosed with ADHD, inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. The focus of evaluation will be (select all that apply) a. academic performance. b. activities of daily living. c. physical growth. d. social relationships. e. personal preception.

a. academic performance. b. activities of daily living. d. social relationships. e. personal preception.

A desired outcome for a client diagnosed with schizophrenia who has a nursing diagnosis of Disturbed sensory perception: auditory hallucinations related to neurobiological dysfunction would be that the client will a. ask for validation of reality. b. describe content of hallucinations. c. demonstrate a cool, aloof demeanor. d. identify prodromal symptoms of disorder.

a. ask for validation of reality.

A coping mechanism used excessively by clients with anorexia nervosa is a. denial. b. humor. c. altruism. d. projection.

a. denial.

The initial task of an outpatient clinic nurse who is working with a client experiencing a sexual disorder is to a. establish trust with the client. b. assess the client's physical health. c. explain that the nurse is a therapeutic agent. d. orient the client to the clinic's programs, which the individual may use as part of therapy.

a. establish trust with the client.

A depressed client is likely to report a sleep disorder that includes a. frequent awakenings during the night. b. nightmares. c. difficulty falling asleep. d. sleepwalking.

a. frequent awakenings during the night.

A client has been hospitalized with anorexia nervosa. The client's weight is 65% of normal. For this client, a realistic short-term goal for the first week of hospitalization would be: By the end of week 1, the client will a. gain a maximum of 3 lb. b. develop a pattern of normal eating behavior. c. discuss fears and feelings about gaining weight. d. verbalize awareness of the sensation of hunger.

a. gain a maximum of 3 lb.

When providing possible interventions to promote the safety of a client reporting symptoms of somnambulism, the nurse includes a. gating the stairways. b. sleeping on a mattress placed on the floor. c. regular bedtime dose of a benzodiazepine. d. avoiding the use of serotonergic medications.

a. gating the stairways.

A 3-year-old has been diagnosed with autism. While there is an absence of language, the child does babble but is indifferent to contact with people. The nurse's initial intervention will be to a. give one-to-one attention in nonverbal parallel play. b. sit next to the child while looking at a picture book. c. feed the child snacks while talking softly. d. sit across from the child at the play table and introduce new toys.

a. give one-to-one attention in nonverbal parallel play.

Sam, a 9-year-old patient, has deficits in social functioning, intellectual functioning, and cannot manage practical aspects of daily life and functioning. You suspect: a. intellectual development disorder (IDD). b. specific learning disorder. c. autism spectrum disorder (ASD). d. attention deficit hyperactivity disorder (ADHD).

a. intellectual development disorder (IDD).

When a client diagnosed with schizophrenia hears voices saying that he is a horrible human being, the nurse can correctly assume that the hallucination a. is a projection of the client's own feelings. b. derives from neuronal impulse misfiring. c. is a retained memory fragment. d. may signal seizure onset.

a. is a projection of the client's own feelings.

A physician describes a client as "malingering." The nurse knows this means that the client a. is falsely claiming to have symptoms. b. experiences symptoms that cannot be explained medically. c. experiences symptoms that have a physiological basis. d. is seeking medication to ease pain of psychological origin.

a. is falsely claiming to have symptoms.

The first-line drug used to treat mania is a. lithium carbonate (Lithium). b. carbamazepine (Tegretol). c. lamotrigine (Lamictal). d. clonazepam (Klonopin).

a. lithium carbonate (Lithium).

The client with bulimia differs from the client with anorexia nervosa by a. maintaining a normal weight. b. holding a distorted body image. c. doing more rigorous exercising. d. purging to keep weight down.

a. maintaining a normal weight.

A desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors would be a. making no attempts at self-harm within 12 hours of admission. b. sleeping soundly for 12 of the next 24 hours. c. willingly taking prescribed medication as offered by staff within 24 hours of admission. d. demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.

a. making no attempts at self-harm within 12 hours of admission.

Generally, ego defense mechanisms a. often involve some degree of self-deception. b. are rarely used by mentally healthy people. c. seldom make the person more comfortable. d. are usually effective in resolving conflicts.

a. often involve some degree of self-deception.

Inability to leave one's home because of avoidance of severe anxiety suggests the anxiety disorder of a. panic attacks with agoraphobia. b. obsessive-compulsive disorder. c. posttraumatic stress response. d. generalized anxiety disorder.

a. panic attacks with agoraphobia.

Use of dissociation most closely resembles a. performing mundane tasks on autopilot. b. developing a headache to avoid an unpleasant task. c. feeling angry with a co-worker who shirks work. d. finding a socially acceptable reason to meet a need.

a. performing mundane tasks on autopilot.

The most common course of schizophrenia is an initial episode followed by a. recurrent acute exacerbations and deterioration. b. recurrent acute exacerbations. c. continuous deterioration. d. complete recovery.

a. recurrent acute exacerbations and deterioration.

Providing care to a client diagnosed with a somatization disorder can be frustrating owing to the client's lack of an organic illness. In order to best manage this barrier to care the staff will a. regularly discuss their feelings about the client during the unit's interprofessional care meetings. b. be required to attend in-services that focus on the various aspects of somatic disorders. c. rotate care of the client among the entire nursing department staff to minimize the frustration. d. provide a unified approach to the client's behavior so as to manage and lessen the barrier itself.

a. regularly discuss their feelings about the client during the unit's interprofessional care meetings.

The priority nursing diagnosis for a hyperactive manic client during the acute phase is a. risk for injury. b. ineffective role performance. c. risk for other-directed violence. d. impaired verbal communication.

a. risk for injury.

A potential problem for a client diagnosed with severe obsessive-compulsive disorder is a. sleep disturbance. b. excessive socialization. c. command hallucinations. d. altered state of consciousness.

a. sleep disturbance.

A 5-year-old who consistently omits the sound for "r" and "s" when speaking is demonstrating a a. speech disorder. b. language disorder. c. social communication disorder. d. specific learning disorder.

a. speech disorder.

A cultural characteristic that may be observed in a teenage, female Hispanic client in times of stress is to a. suddenly tremble severely. b. exhibit stoic behavior. c. report both nausea and vomiting. d. laugh inappropriately.

a. suddenly tremble severely.

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best begin to attack this cognitive distortion by a. suggesting, "Let's look at what you just said, that you can 'never do anything right.'" b. querying, "Tell me what things you think you are not able to do correctly." c. asking, "Is this part of the reason you think no one likes you?" d. saying, "That is the most unrealistic thing I have ever heard."

a. suggesting, "Let's look at what you just said, that you can 'never do anything right.'"

A client reports to the nurse that falling asleep can often take hours. An appropriate intervention would be to a. teach the client how to do progressive relaxation. b. advise the client to drink an ounce or two of brandy at bedtime. c. suggest that the client seek a referral for polysomnography. d. point out that reducing stress at work would be advisable.

a. teach the client how to do progressive relaxation.

The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by a. teaching the family about the disorder and the client's behaviors. b. stressing the need to suppress overt conflict within the family. c. urging the family to demonstrate greater caring for the client. d. encouraging the family to use their usual social behaviors at meals.

a. teaching the family about the disorder and the client's behaviors.

A client is experiencing a panic attack. The nurse can be most therapeutic by a. telling the client to take slow, deep breaths. b. verbalizing mild disapproval of the anxious behavior. c. asking the client what he means when he says "I am dying." d. offering an explanation about why the symptoms are occurring

a. telling the client to take slow, deep breaths.

When a nurse assesses the style of behavior a child habitually uses to cope with the demands and expectations of the environment, he or she is assessing a. temperament. b. resilience. c. vulnerability. d. cultural assimilation.

a. temperament.

When attempting to determine the cause of low sexual drive in either a male or female client, the nurse can expect evaluation of the client's serum level of a. testosterone. b. estrogen. c. thyroxin. d. insulin.

a. testosterone.

To plan care for a manic client the nurse must consider that lithium cannot be started until a. the physical examination and laboratory tests are analyzed. b. the initial doses of antipsychotic medication have brought behavior under control. c. seclusion has proven ineffective as a means of controlling assaultive behavior. d. electroconvulsive therapy can be scheduled to coincide with lithium administration.

a. the physical examination and laboratory tests are analyzed.

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to a. wait quietly for the client to reply. b. prompt the client if the reply is slow. c. repeat the question if the client does not answer promptly. d. review the client's medical record to support the client's response.

a. wait quietly for the client to reply.

A focus for the acute phase of treatment for anorexia nervosa would be a. weight restoration. b. improving interpersonal skills. c. learning effective coping methods. d. changing family interaction patterns.

a. weight restoration.

When a client reports that lithium causes an upset stomach, the nurse suggests taking the medication: a. with meals b. with an antacid c. 30 minutes before meals d. 2 hours after meals

a. with meals

An acute phase nursing intervention aimed at reducing hyperactivity is redirecting the client to a. write in a diary. b. exercise in the gym. c. direct unit activities. d. orient a new client to the unit.

a. write in a diary.

A disorder in which one experiences fear of being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if panic attack occurs is called _________.

agoraphobia

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." The reply by the nurse that clarifies the prevalence of this disease is a. "That is a good observation. Depression does mostly strike people older than 50 years." b. "Depression is seen in people of all ages, from childhood to old age." c. "Depression is most often seen among the middle adult age group." d. "The age of onset for most depressive episodes is given as 18 years."

b. "Depression is seen in people of all ages, from childhood to old age."

An important question to ask during the assessment of a client diagnosed with anxiety disorder is a. "How often do you hear voices?" b. "Have you ever considered suicide?" c. "How long has your memory been bad?" d. "Do your thoughts always seem jumbled?"

b. "Have you ever considered suicide?"

A client reports symptomatology that supports the diagnosis of sleep paralysis. The nurse effectively assesses the client by asking, a. "Do you ever have nighmares?" b. "Have you ever fallen asleep while driving?" c. "Do you have a history of obsessive compulsive behavior?" d. "Is it difficult for you to fall asleep?"

b. "Have you ever fallen asleep while driving?"

An 18-year-old male reports difficulty maintaining an erection. The nurse appropriately assesses this client by inquiring a. "When did this problem begin?" b. "How does the idea of having sex make you feel?" c."Have you ever had your testosterone levels checked?" d. "Are you aware of a history of this problem among the males in your family?"

b. "How does the idea of having sex make you feel?"

Which assessment question should be asked of a client suspected of demonstrating characteristics of anorexia nervosa? a. "Do you find yourself feeling hungry?" b. "How would you describe your body?" c. "How often do you force yourself to vomit?" d. "Why do you choose to take laxatives?"

b. "How would you describe your body?"

A statement that would show acceptance of a depressed, mute client would be a. "I will be spending time with you each day to try to improve your mood." b. "I would like to sit with you for 15 minutes now and again this afternoon." c. "Each day we will spend time together to talk about things that are bothering you." d. "It is important for you to share your thoughts with someone who can help you evaluate your thinking."

b. "I would like to sit with you for 15 minutes now and again this afternoon."

Erin has just been diagnosed with dissociative identity disorder. She asks you, "What exactly are 'alters'? My provider told me I have several of them." Which statement by Erin illustrates that the education you provided has been effective? a. "So, alters are based in mysticism and religiosity, such as demons." b. "So, alters are separate personalities with their own characteristics that take over during stress." c. "So, alters are never aware of each other." d. "So, alters are just like me, but they have no memory of the trauma I went through."

b. "So, alters are separate personalities with their own characteristics that take over during stress."

A female patient tells the nurse that she would like to begin taking St. John's wort for depression. What teaching should the nurse provide? a. "St. John's wort should be taken several hours after your other antidepressant." b. "St. John's wort has generally been shown to be effective in treating depression." c. "This supplement is safe to take if you are pregnant." d. "St. John's wort is regulated by the FDA, so you can be assured of its safety."

b. "St. John's wort has generally been shown to be effective in treating depression."

Taylor is a 3-year-old boy just diagnosed with autism spectrum disorder. Taylor's mom is tearful and states, "Dr. Coolidge said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" Your best response, based on knowledge of autism treatment, is: a. "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." b. "Starting him on treatment now gives Taylor a much greater chance for a productive life." c. "If Taylor starts therapy now, he will be able to stop therapy sooner." d. "If you have questions, its best to ask Dr. Coolidge."

b. "Starting him on treatment now gives Taylor a much greater chance for a productive life."

A 27-year-old patient states that since her marriage ended 2 years ago, she has found herself lacking interest and motivation in sexual activity. Which response is most likely to be therapeutic? a. "What is your moral perspective regarding sexual activity outside of marriage?" b. "Tell me more about your life since your marriage ended." c. "Often physical illness causes decreased desire in women." d. "This is a common problem, especially considering all the stress you have been through."

b. "Tell me more about your life since your marriage ended."

Emily is a veteran returning from Iraq. Ever since Emily participated in a village raid where explosives were used, she has been unable to walk. All diagnostic testing has been negative for any physical abnormalities, and she was diagnosed with conversion disorder. She asks you what that means. Your best response would be: a. "Your legs don't work because your brain is screwed up." b. "Your emotional distress is being expressed as a physical symptom." c. "You are making up your symptoms as a cry for help." d. "You are overly anxious about having a severe illness."

b. "Your emotional distress is being expressed as a physical symptom."

The most likely client to initially demonstrate behaviors suggesting a somatic disorder is a a. 13-year-old male b. 23-year-old female c. 33-year-old male d. 43-year-old female

b. 23-year-old female

What can be said about the comorbidity of anxiety disorders? a. Anxiety disorders generally exist alone. b. A second anxiety disorder may coexist with the first. c. Anxiety disorders virtually never coexist with mood disorders. d. Substance abuse disorders rarely coexist with anxiety disorders.

b. A second anxiety disorder may coexist with the first.

The nurse is reviewing orders given for a patient with depression. Which order should the nurse question? a. A low starting dose of a tricyclic antidepressant b. An SSRI given initially with an MAOI c. Electroconvulsive therapy to treat suicidal thoughts d. Elavil to address the patient's agitation

b. An SSRI given initially with an MAOI

For assessment purposes, the nurse should identify the body system most at risk for decompensation during a severe manic episode as: a. Renal b. Cardiac c. Endocrine d. Pulmonary

b. Cardiac

Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation? a. Constipation b. Death anxiety c. Activity intolerance d. Self-care deficit: bathing/hygiene

b. Death anxiety

The nurse is caring for a patient with attention deficit hyperactivity disorder. The child has been prescribed methylphenidate (Ritalin). Which of the following symptoms are side effects the nurse will monitor for? (Select all that apply.) a. Hypotension b. Decreased appetite c. Sedation d. Insomnia e. Headache f. Seizure

b. Decreased appetite d. Insomnia e. Headache

What statement about the comorbidity of depression is accurate? a. Depression most often exists in an individual as a single entity. b. Depression is commonly seen in individuals with medical disorders. c. Substance abuse and depression are seldom seen as comorbid disorders. d. Depression may coexist with other disorders but is rarely seen with schizophrenia.

b. Depression is commonly seen in individuals with medical disorders.

Which of the following statements about dissociative disorders is true? a. Dissociative symptoms are under the person's conscious control. b. Dissociative symptoms are not under the person's conscious control. c. Dissociative symptoms are usually a cry for attention. d. Dissociative symptoms are always negative.

b. Dissociative symptoms are not under the person's conscious control.

When you are educating Erin and her mother about the medication dosage and side effects, Erin becomes upset and tearful, stating, "No! I will not take that medication!" Which of the following is the most likely reason for Erin's feelings? a. Erin feels embarrassed to be taking psychiatric medication. b. Erin is upset about the possible side effect of weight gain. c. Erin is worried about the common adverse effect of sexual problems. d. Erin's resistance is typical of her characteristics of rigidity and needing control.

b. Erin is upset about the possible side effect of weight gain.

Which of the following are true regarding feeding disorders in children? Select all that apply. a. Feeding disorders usually reflect poor parenting b. Feeding disorders are often manifested in children with developmental delays c. Feeding disorders are most often treated with a punishment system d. In many cases, toddler mealtime difficulties spontaneously resolve with no intervention e. Behavior modification has been found to be effective in treating feeding disorders

b. Feeding disorders are often manifested in children with developmental delays d. In many cases, toddler mealtime difficulties spontaneously resolve with no intervention e. Behavior modification has been found to be effective in treating feeding disorders

Nico, a 22-year-old patient, is diagnosed with schizophrenia. Which of the following symptoms would alert a provider to a possible diagnosis of schizophrenia? a. Excessive sleeping with disturbing dreams b. Hearing voices telling him to hurt his roommate c. Withdrawal from college because of failing grades d. Chaotic and dysfunctional relationships with his family and peers

b. Hearing voices telling him to hurt his roommate

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? a. Overeating b. Hypervigilance c. A drive to be perfect d. Passivity

b. Hypervigilance

Studies of clients diagnosed with posttraumatic stress disorder suggest that the stress response of which of the following is considered abnormal? a. Brainstem b. Hypothalamus-pituitary-adrenal system c. Frontal lobe d. Limbic system

b. Hypothalamus-pituitary-adrenal system

Jerry is a 72-year-old patient with Parkinson's disease and anxiety. He is living by himself and has had several falls lately. His provider orders lorazepam, 1 mg PO bid, for anxiety. You question this order because: a. Jerry may become addicted faster than younger patients. b. Jerry is at risk for falls. c. Jerry has a history of nonadherence with medications. d. Jerry should be treated with cognitive therapies rather than medication because of his advanced age.

b. Jerry is at risk for falls.

Luisa is the nurse assigned to work with Juan, a male on a stepdown unit. He is in counseling as part of the process of seeking sexual reassignment surgery and has female clothing in the hospital locker. Luisa is nervous about working with someone like Juan and spends only the briefest amounts of time responding to his needs. What is/are the best description(s) of what is occurring here? Select all that apply. a. As long as Juan's minimal care needs are addressed, Luisa is within her rights to respond this way. b. Luisa is failing to maintain professional objectivity because of her values and beliefs about this particular patient's decisions and behavior. c. Luisa is experiencing a common negative response to a situation about which she has limited knowledge and that she does not understand. d. Luisa may be having difficulty looking beyond Juan's gender issues and as a result is failing to see or respond to him as a person. e. Luisa is avoiding Juan because she is afraid that she cannot mask the disapproval she feels.

b. Luisa is failing to maintain professional objectivity because of her values and beliefs about this particular patient's decisions and behavior. c. Luisa is experiencing a common negative response to a situation about which she has limited knowledge and that she does not understand. d. Luisa may be having difficulty looking beyond Juan's gender issues and as a result is failing to see or respond to him as a person. e. Luisa is avoiding Juan because she is afraid that she cannot mask the disapproval she feels.

You are caring for Susannah, a 29-year-old who has been diagnosed with dissociative identity disorder. She was recently hospitalized after coming to the emergency room with deep cuts on her arms with no memory of how this occurred. The priority nursing intervention for Susannah is: a. Assisting in recovering memories of abuse. b. Maintain 1:1 observation. c. Teach coping skills and stress-management strategies. d. Refer for integrative therapy.

b. Maintain 1:1 observation.

Which therapeutic intervention can the nurse implement personally to help a client diagnosed with a mild anxiety disorder regain control? a. Flooding b. Modeling c. Thought stopping d. Systematic desensitization

b. Modeling

Nadia has been diagnosed with bipolar disorder. Which is an outcome for Nadia in the continuation of treatment phase of bipolar disorder? a. Patient will avoid involvement in self-help groups b. Patient will adhere to medication regimen c. Patient will demonstrate euphoric mood d. Patient will maintain normal weight

b. Patient will adhere to medication regimen

A suitable outcome criterion for the nursing diagnosis Ineffective coping related to dependence on pain relievers to treat chronic pain of psychological origin is: a. Patient will participate in self-care with optimal participation b. Patient will learn and practice effective coping skills c. Patient will demonstrate improved self-esteem as evidenced by focusing less on weakness d. Patient will replace demanding, manipulative behaviors with more socially acceptable behavior.

b. Patient will learn and practice effective coping skills

A slightly obese client reports falling asleep during the daytime even though she has slept all night. Her husband says she snores, and her blood pressure is noted to be in the low hypertensive range. The nurse anticipates that the client will be scheduled for which diagnostic test? a. Hypertension screening b. Polysomnography c. Glycosylated hemoglobin d. Positron emission tomography

b. Polysomnography

Mark, a 32-year-old patient with schizophrenia, is found in a closet with an empty 2-liter bottle of cola taken from the staff refrigerator. The bottle had been full. The patient has also been drinking more from the hallway water cooler and taking drinks from his peers' dinner trays. Recently, staff has noticed an increase in auditory hallucinations and the onset of confusion. Which response would be appropriate? a. Place Mark on every-15-minute checks to identify an further deterioration. b. Restrict his access to fluids, and evaluate for water intoxication via daily weights c. Attempt to distract the patient from excess fluid intake and other bizarre behavior d. Request an increase in antipsychotic medication, owing to worsening of his psychosis

b. Restrict his access to fluids, and evaluate for water intoxication via daily weights

According to the National Sleep Foundation, which condition is an example of a social problem that may be a result of sleepiness? a. Narcolepsy b. Road rage c. Alcohol abuse d. Insomnia

b. Road rage

Sasha has been having angry outbursts with staff and peers on the unit. You are talking with Sasha on her third day of admission. You ask whether she is having any thoughts of suicide. Sasha becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" Your response is based on the knowledge that: a. Sasha is getting better because she is able to be assertive. b. Sasha may be at high risk for self-harm. c. Sasha is probably experiencing transference. d. Sasha may be angry at someone else and projecting that anger to staff.

b. Sasha may be at high risk for self-harm.

Which of the following is true of the relationship between bipolar disorder and suicide? a. Patients need to be monitored only in the depressed phase because this is when suicides occur. b. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. c. Patients with bipolar disorder are not considered high risk for suicide. d. As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

b. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.

Ed, a registered nurse, is planning care for a patient with primary insomnia. What is the appropriate outcome? a. The patient will sleep 12 hours nightly b. The patient will go to sleep and wake up at consistent times. c. The patient will take one nap daily to restore energy d. The patient will drink a warm cup of tea before bedtime

b. The patient will go to sleep and wake up at consistent times.

A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance? a. The side-effects are unpleasant. b. The voices tell the client to stop taking it. c. The client prefers to feel "high" and energetic. d. The client feels well and denies the possibility of recurrence.

b. The voices tell the client to stop taking it.

Lucas is a nurse on a medical floor caring for Kelly, a 48-year-old patient with newly diagnosed type 2 diabetes. He realizes that depression is a complicating factor in the patient's adjustment to her new diagnosis. What problem has the most potential to arise? a. Development of agoraphobia b. Treatment nonadherance c. Frequent hypoglycemic reactions d. Sleeping rather than checking blood sugar

b. Treatment nonadherance

Which symptom related to communication is likely to be present in a patient experiencing mania? a. Mutism b. Verbosity c. Poverty of ideas d. Confabulation

b. Verbosity

Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? a. Weigh two times daily, then three times weekly. b. Weigh fully clothed before breakfast. c. Do not reweigh client when client requests. d. Permit no oral intake before weighing.

b. Weigh fully clothed before breakfast.

The symptom the nurse can expect a client with depersonalization disorder to manifest is a. aimless wandering with confusion and disorientation. b. a feeling of detachment from one's body or mental processes. c. existence of two or more personalities that take control of behavior. d. worry about having a serious disease based on symptom misinterpretation.

b. a feeling of detachment from one's body or mental processes.

An older adult who reports taking a late afternoon nap every day to make up for his disrupted sleep at night still feels tired. The nurse explains that a. an afternoon nap includes a great deal of REM sleep. b. a late afternoon nap does not compensate for a lack of nighttime sleep. c. a noontime nap includes very little REM sleep. d. the elderly always need fewer than 6 hours of sleep each night.

b. a late afternoon nap does not compensate for a lack of nighttime sleep.

An obsession is defined as a. thinking of an action and immediately taking the action. b. a recurrent, persistent thought or impulse. Correct c. an intense irrational fear of an object or situation. d. a recurrent behavior performed in the same manner.

b. a recurrent, persistent thought or impulse.

The nurse anticipates that the nursing history of a client diagnosed with obsessive compulsive disorder (OCD) will reveal a. a history of childhood trauma. b. a sibling with the disorder. c. an eating disorder. d. a phobia as well.

b. a sibling with the disorder.

A desired outcome for the maintenance phase of treatment for a manic client would be that the client will a. exhibit optimistic, energetic, playful behavior. b. adhere to follow-up medical appointments. c. take medication more than 50% of the time. d. use alcohol to moderate occasional mood "highs."

b. adhere to follow-up medical appointments.

Stella brings her mother, Dorothy, to the mental health outpatient clinic. Dorothy has a history of anxiety. Stella and Dorothy both give information for the assessment interview. Stella states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." You suspect: a. panic disorder. b. adult separation anxiety disorder. c. agoraphobia. d. social anxiety disorder.

b. adult separation anxiety disorder.

The defense mechanisms that can only be used in healthy ways include a. suppression and humor. b. altruism and sublimation. c. idealization and splitting. d. reaction formation and denial.

b. altruism and sublimation.

Bupropion (Wellbutrin), although seemingly effective, is contraindicated in patients who purge because of a. historically poor patient compliance. b. an increased risk of seizures. c. the long-term effects on liver function. d. the potential to cause gastric ulcers.

b. an increased risk of seizures.

When a couple in their early 40s tells the nurse that they have not had sexual relations in more than 5 years, the nurse should initially a. mention that a lack of sexual desire is not an uncommon problem. b. ask whether the couple finds this troublesome and are seeking help. c. ask the couple about any medical conditions they have. d. remain noncommittal and allow them to take the lead.

b. ask whether the couple finds this troublesome and are seeking help.

The initial nursing action for a newly admitted anxious client is to a. assess the client's use of defense mechanisms. b. assess the client's level of anxiety. c. limit environmental stimuli. d. provide antianxiety medication.

b. assess the client's level of anxiety.

A 7-year-old who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with the DSM-5 diagnosis of a. attention deficit disorder. b. attention deficit hyperactivity disorder. c. autism. d. conduct disorder.

b. attention deficit hyperactivity disorder.

It can be said that the onset of most anxiety disorders occurs a. before the age of 20 years. b. before the age of 40 years. c. after the age of 40 years. d. scattered throughout the life span.

b. before the age of 40 years.

A client is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the client reports a. that his symptoms started right after he was robbed at gunpoint. b. being so worried he hasn't been able to work for the last 12 months. c. that eating in public makes him extremely uncomfortable. d. repeatedly verbalizing his prayers helps him feel relaxed.

b. being so worried he hasn't been able to work for the last 12 months.

A social behavior that is often a result of a child having been abused is a. speech disorders. b. bullying of others. c. eating disorders. d. delayed motor skills.

b. bullying of others.

The nurse can expect a client demonstrating typical manic behavior to be attired in clothing that is a. dark colored and modest. b. colorful and outlandish. c. compulsively neat and clean. d. ill-fitted and ragged.

b. colorful and outlandish.

Therapeutic intervention for a client with a somatoform disorder would include a. steering conversation away from the client's feelings. b. conveying an interest in the client rather than in the symptoms. c. encouraging the client to use benzodiazepines liberally. d. encouraging the client to rely on the nurse to meet the client's needs.

b. conveying an interest in the client rather than in the symptoms.

A man continues to speak of his wife as though she were still alive, 3 years after her death. This behavior suggests the use of a. altruism. b. denial. c. undoing. d. suppression.

b. denial.

A client with bulimia nervosa uses enemas and laxatives to purge to maintain her weight. The imbalance for which the nurse should assess is a(n) a. increase in the red blood cell count. b. disruption of the fluid and electrolyte balance. c. elevated serum potassium level. d. elevated serum sodium level.

b. disruption of the fluid and electrolyte balance.

An appropriate intervention for a 12-year-old child demonstrating faulty personality development associated with ADHD would include a. regular entries into a personal sleep hygiene journal. b. enrollment in family and individual group therapies. c. involvement in family menu planning and food shopping. d. after school tutoring to help maintain passing grades.

b. enrollment in family and individual group therapies.

A client prescribed a monamine oxidase inhibitor (MOA) has a pass to go out to lunch. Given a choice of the following entrees, the client can safely eat a. avocado salad plate. b. fruit and cottage cheese plate. c. kielbasa and sauerkraut. d. liver and onion sandwich.

b. fruit and cottage cheese plate

The primary difference between a factitious disorder and other somatic disorders is that factitious disorders a. respond well to confrontation as a primary therapeutic technique. b. have a symptomatology that is actually controlled by the client. c. have their origins in depression and anxiety. d. are always self-directed.

b. have a symptomatology that is actually controlled by the client.

Ellie, a 38-year-old patient referred for sleep studies, reports frequent daytime lethargy, unintended lapses into sleep, and never feeling rested on awakening in the morning. Ellie's symptoms describe: a. circadian rhythm disorder. b. hypersomnolence. c. rapid eye movement (REM) sleep behavior disorder. d. breathing-related sleep disorder.

b. hypersomnolence.

A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to reveal a. tachycardia. b. hypokalemia. c. hypercalcemia. d. hypolipidemia.

b. hypokalemia.

Regarding the provision of care for clients experiencing sexual disorders, a nurse generalist a. helps clients make significant changes in sexual function. b. identifies alterations in normal sexuality and relationships. c. deals with sexual dysfunctions rather than paraphilias. d. offers advice about orgasmic disorders.

b. identifies alterations in normal sexuality and relationships.

An outcome for a manic client during the acute phase that would indicate that the treatment plan was successful would be that the client a. reports racing thoughts. b. is free of injury. c. is highly distractible. d. ignores food and fluid.

b. is free of injury.

Empathic listening is therapeutic because it focuses on a. enhancing self-esteem. b. lessening feelings of isolation. c. reducing anxiety. d. encouraging resilience.

b. lessening feelings of isolation.

Selective inattention is first noted when experiencing anxiety that is a. mild. b. moderate. c. severe. d. panic.

b. moderate.

When a toddler's mother is hospitalized for several months, the nursing diagnosis Risk for impaired parent/child attachment related to: prolonged separation has been included into a child's plan of care. The most appropriate outcome would be that a. the mother is discharged and returned home as soon as possible. b. mother and child show signs of healthy bonding. c. the father is able to assume the mother's role in her absence. d. the child is able to transfer nuturing needs to another available adult.

b. mother and child show signs of healthy bonding.

A teenager changes study habits to earn better grades after initially failing a test. This behavioral change is likely a result of a. a rude awakening. b. normal anxiety. c. trait anxiety. d. altruism.

b. normal anxiety.

Disorders that involve variations in sexual behaviors are called a. pedophilias. b. paraphilias. c. frotteurism. d. sadomasochism.

b. paraphilias.

A child diagnosed with autism will demonstrate impaired development in a. adhering to routines. b. playing with other children. c. swallowing and chewing. d. eye-hand coordination.

b. playing with other children.

You are interviewing Lance, a 31-year-old patient who has been referred to the sexual disorders clinic by his primary care provider. When describing his problem, Lance states, "I can have an orgasm, no problem. It just happens way too soon." Lance is describing: a. erectile disorder. b. premature ejaculation. c. delayed ejaculation. d. male hypoactive sexual desire disorder.

b. premature ejaculation.

The most beneficial nursing intervention directed toward minimizing the discomfort associated with conducting a sexually focused assessment is to a. assure the client that the responses will be kept confidential. b. provide the client with a rationale for asking the questions. c. begin with the most relevant, nonpersonal question. d. project a relaxed, causal demeanor when questioning the client.

b. provide the client with a rationale for asking the questions.

A non-habit-forming melatonin receptor agonist often prescribed for insomnia is a. zolpidem (Ambien). b. ramelteon (Rozerem). c. eszopiclone (Lunesta). d. zaleplon (Sonata).

b. ramelteon (Rozerem).

A 20-year-old was sexually molested at age 10, but he can no longer remember the incident. The ego defense mechanism in use is a. projection. b. repression. c. displacement. d. reaction formation.

b. repression.

A child who is able to regain mental stability after a traumatic event is said to be a. autonomous. b. resilient. c. mature. d. independent.

b. resilient.

A nursing diagnosis that should be considered for a child with attention deficit hyperactivity disorder is a. anxiety. b. risk for injury. c. defensive coping. d. impaired verbal communication.

b. risk for injury.

When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention would be to a. question the client's motive. b. set verbal limits. c. initiate physical confrontation. d. prepare the client for seclusion.

b. set verbal limits.

When discussing somatic disorders from a cultural perspective, it is true that a. somatic disorders are rarely observed in males. b. somatic symptoms vary widely from culture to culture. c. underdeveloped countries rarely tolerate somatic disorders. d. secondary gain is seldom a factor in somatic disorders.

b. somatic symptoms vary widely from culture to culture.

The major reason for hospitalization for depressed patients is: a. inability to go to work. b. suicidal ideation. c. loss of appetite. d. psychomotor agitation.

b. suicidal ideation.

A recovering alcoholic client is being treated for a sleep disorder. Research has shown that a successful sleep treatment plan is vital to support the client's a. ability to work and support himself. b. sustaining his continued sobriety. c. re-integration into positive interpersonal relationships. d. general health and wellness.

b. sustaining his continued sobriety.

Carina, a student nurse on rotation in the emergency department, is assigned to care for Daniel, who was brought in from the local prison with suspected appendicitis. Daniel is in prison for child rape. Carina's niece was recently sexually abused, and Carina feels this type of crime is reprehensible. She begins feeling very upset and disgusted with Daniel because of his crime and doesn't know how she can care for him without letting her feelings show. Carina's best course of action is to: a. refuse the assignment because her personal feelings will prevent her from giving good care. b. talk with her faculty member or an experienced nurse in the emergency department. c. perform the activities of care but not engage in conversation with the patient. d. tell Daniel honestly how she feels and let him choose to request a different nurse.

b. talk with her faculty member or an experienced nurse in the emergency department.

The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of a. acute dystonia. b. tardive dyskinesia. c. cholestatic jaundice. d. pseudoparkinsonism.

b. tardive dyskinesia.

A nursing intervention designed to help a schizophrenic client manage relapse is to a. schedule the client to attend group therapy that includes those who have relapsed. b. teach the client and family about behaviors associated with relapse. c. remind the client of the need to return for periodic blood draws to minimize the risk for relapse. d. help the client and family adapt to the stigma of chronic mental illness and periodic relapses.

b. teach the client and family about behaviors associated with relapse.

A child reared in a minority culture is at greatest risk for a. eating- and sleep-related disorders. b. traumatic experiences in early childhood. c. bullying. d. homicidal thoughts.

b. traumatic experiences in early childhood.

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client diagnosed with severe depression. The most reliable evaluation of outcomes will be based on the client's a. energy level. b. weekly weights. c. observed eating patterns. d. statement of appetite.

b. weekly weights.

A client is displaying symptomatology reflective of a panic attack. In order to help the client regain control, the nurse responds, a. "You need to calm yourself." b. "What is it that you would like me to do to help you?" c. "Can you tell me what you were feeling just before your attack?" d. "I will get you some medication to help calm you."

c. "Can you tell me what you were feeling just before your attack?"

A client tells the nurse, "I just don't sleep more than 5 hours at night." The nurse responds best by asking a. "Are you aware that some people require less sleep than others?" b. "When did this pattern of sleep start for you?" c. "Do you usually feel rested and alert when you get up?" d. "Are you taking any medication that could affect your sleep?"

c. "Do you usually feel rested and alert when you get up?"

Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? a. "I purge only once a day now instead of twice." b. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." c. "I am a hard worker and I am very compassionate toward others." d. "I always purge when I'm alone so that I'm not a bad role model for my younger sister."

c. "I am a hard worker and I am very compassionate toward others."

Which statement made by a client would support the diagnosis of hypochondriasis? a. "I feel confused and disoriented." b. "I feel as though I'm outside my body watching what is happening." c. "I know I have cancer, but the doctors just cannot find it." d. "I woke up one morning, and my left leg was paralyzed from the knee down."

c. "I know I have cancer, but the doctors just cannot find it."

Sasha is a 38-year-old patient admitted with major depression. Which of the following statements Sasha makes alerts you to a common accompaniment to depression? a. "I still pray and read my Bible every day." b. "My mother wants to move in with me, but I want to independent." c. "I still feel bad about my sister dying of cancer. I should have done more for her!" d. "I've heard others say that depression is a sign of weakness."

c. "I still feel bad about my sister dying of cancer. I should have done more for her!"

A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. A therapeutic response for the nurse would be a. "You are safe here in the hospital; nothing bad will happen to you." b. "The voices are wrong about the hospital food. It is not contaminated." c. "I understand that the voices are very real to you, but I do not hear them." d. "Other people are eating the food, and nothing is happening to them."

c. "I understand that the voices are very real to you, but I do not hear them."

Sasha is started on fluoxetine. Which statement by Sasha indicates that she understands the medication teaching you have provided? a. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." b. "I will not take any over-the-counter medication while on the fluoxetine." c. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." d. "I will report increased thirst and urination to my provider."

c. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away."

A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be a. "What an offensive thing to suggest!" b. "I don't have sex with clients." c. "It's time to work on your art project." d. "Let's walk down to the seclusion room."

c. "It's time to work on your art project."

Since learning that he will have a trial pass to a new group home tomorrow, Luke's usual behavior has changed. He has started to pace, has become distracted, and is breathing rapidly. He has trouble focusing on anything other than the group home issue and complains that he suddenly feels nauseated. Which initial nursing response is most appropriate for Luke's level of anxiety? a. "You seem anxious. Would you like to talk about how you are feeling?" b. "If you do not calm down, I will have to give you prn medication to help you." c. "Luke, slow down. Listen to me. You are safe. Take a deep breath, and let's go to a quieter place." d. "We can delay the visit to the group home if that would help you calm down."

c. "Luke, slow down. Listen to me. You are safe. Take a deep breath, and let's go to a quieter place."

You are interviewing Matthew, a 39-year-old patient with major depression. You wish to ask Matthew about any sexual dysfunction that may be arising as the result of depression. Which way of opening up the subject may increase the patient's comfort in discussing this with you? a. "This is embarrassing for both of us, but I need to ask you about sexual problems." b. "I have to ask you about sexual issues, but since I am a professional, you shouldn't feel hesitant to discuss sexual issues with me." c. "Many people who have depression also experience sexual problems. Are there any problems you want to talk about?" d. "I am going to ask you about sexual problems, but you can be reassured everything we talk about is confidential and I won't judge you."

c. "Many people who have depression also experience sexual problems. Are there any problems you want to talk about?"

Kyla asks you to explain what basal sleep requirement is. Your best response is: a. "The basal temperature of your body needed to induce the best sleep." b. "The sleep time by your body needed to repair cellular damage." c. "The amount of sleep needed to be fully awake and perform well in the daytime." d. "The amount of sleep needed to transition to REM sleep."

c. "The amount of sleep needed to be fully awake and perform well in the daytime."

You are caring for Yolanda, a 67-year-old patient who has been receiving hemodialysis for 3 months. Yolanda reports that she feels angry whenever it is time for her dialysis treatment. You attribute this to: a. Organic changes in Yolanda's brain b. A flaw in Yolanda's personality c. A normal response to grief and loss d. Denial of the reality of a poor prognosis

c. A normal response to grief and loss

Which room placement would be best for a client experiencing a manic episode? a. A shared room with a client with dementia b. A single room near the unit activities area c. A single room near the nurses' station d. A shared room away from the unit entrance

c. A single room near the nurses' station

Which symptom would NOT be assessed as a positive symptom of schizophrenia? a. Delusion of persecution b. Auditory hallucinations c. Affective flattening d. Idea of reference

c. Affective flattening

Jordan is a 21-year-old who was recently diagnosed with schizophrenia He has had to drop out of college as the positive symptoms of his disease have made it impossible for him to pursue his dream of being an architect. He presents to the emergency department with flat affect, depressed mod, and having auditory hallucinations telling him he is "no good to anyone anymore." Which of the following statement is true regarding depression and schizophrenia? a. Anxiety and substance abuse are comorbid with schizophrenia, but not depression or dysphoria b. It is important to assess for depression and suicidal ideation in patients with schizophrenia, but suicide rarely occurs in this population of clients c. Assessing for depression and suicidal ideation in patients with schizophrenia is important since almost half of people with schizophrenia attempt suicide d. The medications that will be given to control the positive symptoms of schizophrenia, such as auditory hallucinations, will alleviate any depressive symptoms a patient may have.

c. Assessing for depression and suicidal ideation in patients with schizophrenia is important since almost half of people with schizophrenia attempt suicide

The nurse is developing a plan of care for a teenage patient with attention deficit hyperactivity disorder who is at risk for self-harm due to poor judgement, high risk-taking behaviors, and impulsivity. Which of the following is the priority nursing intervention? a. Schedule a regular nurse-patient session daily, and encourage her to explore stressors that may worsen her depressed mood. b. Develop a "no self-harm" contract with the patient, and encourage her to engage in all unit activities. c. Assign a staff member one-to-one close observation until the treatment team determines she is no longer a risk for self-harm. d. The patient is to wear hospital-issue clothing (pajamas) and sit/sleep within view of staff until the physician determines she is no longer at risk for self-harm.

c. Assign a staff member one-to-one close observation until the treatment team determines she is no longer a risk for self-harm.

Tony, a 45-year-old patient with schizophrenia, sometimes moves his lips silently or murmurs to himself when he does not realize others are watching. Sometimes when talking to others, he suddenly stops, appears distracted for a moment, and then resumes. Based on these observations, Tony most likely is experiencing: a. Illusions b. Delusional thinking c. Auditory hallucinations d. Impaired reality testing

c. Auditory hallucinations

The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse's discharge plan of care? a. Pharmacological teaching b. Safety risk c. Awareness of symptoms that increase depression d. The need for interpersonal contact

c. Awareness of symptoms that increase depression

Ashley is a 21-year-old college student who was sexually assaulted at a party. She was seen in the local emergency department and referred for counseling after being diagnosed by the provider on call as having acute stress disorder. Which of the following treatment modalities would you expect to see used in therapy with Ashley? a. Aversion therapy b. Stress-reduction therapy c. Cognitive-behavior therapy d. Short-term classical analysis therapy

c. Cognitive-behavior therapy

You find that you feel uncomfortable talking with Lance about his sexual problem. Which of the following actions you could take would be appropriate? a. Ask another nurse to take over the interview so you don't project your feelings onto the patient. b. Pause the interview and take time to gather your thoughts and do positive self-talk. c. Continue the interview using an appropriate professional tone and matter-of-fact approach. d. Ask Lance whether he would feel more comfortable speaking with a physician about his problem.

c. Continue the interview using an appropriate professional tone and matter-of-fact approach.

Which item of data should be routinely gathered during assessment of a client with a somatoform disorder? a. Potential for violence b. Level of confusion c. Dependence on medication d. Personal identity disturbance

c. Dependence on medication

Ellie asks what medication may help her condition. Your response is based on the knowledge that: a. there is no effective medication treatment for hypersomnolence disorder. b. medication therapy with benzodiazepines may be initiated. c. Ellie may be prescribed a stimulant. d. Ellie will be started on an anticholinesterase inhibitor for increased cognition.

c. Ellie may be prescribed a stimulant.

What would be an appropriate expected outcome of Emily's treatment plan? a. Emily will walk unassisted within 1 week. b. Emily will return to a pre-illness level of functioning within 2 weeks. c. Emily will be able to state two new effective coping skills within 2 weeks. d. Emily will assume full self-care within 3 weeks.

c. Emily will be able to state two new effective coping skills within 2 weeks.

Hallie's father, Brent, has now been diagnosed with PTSD as well as Hallie. Which of the following symptoms would lead a provider to suspect PTSD? (select all that apply): a. Visiting the scene of the accident over and over b. Talking with strangers about the events of the accident c. Flashbacks of the accident d. Hypervigilance e. Irritability f. Difficulty concentrating g. Mania

c. Flashbacks of the accident d. Hypervigilance e. Irritability f. Difficulty concentrating

Which behavior is most indicative of a 4-year-old child diagnosed with Tourette's syndrome? a. Difficulty in social relationships b. Humming while performing activities that require concentration c. Frequent eye blinking d. Difficulty in completing tasks on time

c. Frequent eye blinking

A young male patient tells you that somehow he feels that the should not be a man and that inside he is a woman. This is likely an example of: a. Fetishistic disorder b. Frotteuristic disorder c. Gender dysphoria d. Transvestic disorder

c. Gender dysphoria

Select the nursing diagnosis least likely to be chosen after analysis of data pertinent to a client with post-partum depression. a. Impaired parenting b. Ineffective role performance c. Health-seeking behaviors d. Risk for impaired parent/infant/child attachment

c. Health-seeking behaviors

Which disorder is characterized by the client's misinterpretation of physical sensations or feelings? a. Somatic disorder b. Factitious disorder c. Illness anxiety disorder d. Conversion disorder

c. Illness anxiety disorder

The nurse is admitting a patient who weighs 100 pounds, is 66 inches tall, and is below ideal body weight. The patient's blood pressure is130/80 mm Hg, pulse is 72 beats per minute, potassium is 2.5 mmol/L. and ECG is abnormal. Her teeth enamel is eroded, her hands are shaking, and her parotid gland is enlarged. The patient states, "I am really nervous about coming to this unit." What is the priority nursing diagnosis? a. Powerlessness b. Risk for injury c. Imbalanced nutrition: Less than body requirements d. Anxiety

c. Imbalanced nutrition: Less than body requirements

Which nursing diagnosis should be investigated for clients with somatoform disorders? a. Deficient fluid volume b. Self-care deficit c. Ineffective coping d. Delayed growth and development

c. Ineffective coping

Which nursing diagnosis would be most useful for clients with anxiety disorders? a. Excess fluid volume b. Disturbed body image c. Ineffective role performance d. Disturbed personal identity

c. Ineffective role performance

The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? a. Having the client repeatedly touch "dirty" objects b. Not allowing the client to seek reassurance from staff c. Not allowing the client to wash hands after touching a "dirty" object d. Telling the client that he or she must relax whenever tension mounts

c. Not allowing the client to wash hands after touching a "dirty" object

Which of the following is true regarding schizophrenia treatment and outcomes? a. If treated quickly following diagnosis, schizophrenia can be cured. b. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. c. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. d. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.

c. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability.

Which patient behavior would alert the nurse to a circadian rhythm sleep disorder? a. Excessive sleepiness for at least 1 month, accompanied by prolonged sleep episodes b. Multiple episodes of brief daytime sleeping followed by disturbed nighttime sleep c. Persistent patterns of sleep disruption after traveling for business d. Repeated episodes of upper airway collapse and obstruction that results in sleep fragmentation.

c. Persistent patterns of sleep disruption after traveling for business

Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa ? a. Disturbed body image b. Chronic low self-esteem c. Risk for injury: electrolyte imbalance d. Ineffective coping: impulsive responses to problems

c. Risk for injury: electrolyte imbalance

Declan is being discharged from the psychiatric unit on risperidone (Risperdal). You are providing medication teaching to Declan and his mother, who is his primary caregiver. Which of the following statements is the appropriate response to Declan's mother's question regarding the risk for extrapyramidal side effects (EPSs) while taking risperidone? a. All antipsychotic medications have an equal chance of producing EPSs. b. Newer antipsychotic medications have a higher c. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics. d. Advise Declan's mother to ask the provider to change the medication to clozapine instead of risperidone.

c. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics.

Which of the following is true of transvestic disorder? a. Most people with this disorder are homosexual. b. Only men are diagnosed with transvestic disorder. c. Sexual orientation has no bearing on transvestic disorder. d. Transvestic behavior develops in early to middle adulthood.

c. Sexual orientation has no bearing on transvestic disorder.

Which disorder places the client at highest risk for developing a coexisting substance abuse disorder? a. Conversion disorder b. Factitious disorder c. Somatoform pain disorder d. Illness anxiety disorder

c. Somatoform pain disorder

Which intervention would be removed from the plan of care for a client diagnosed with bulimia nervosa? a. Teach that fasting sets one up to binge eat. b. Assist client to identify trigger foods. c. Support importance of avoiding forbidden foods. d. Teach client to plan and eat regularly scheduled meals.

c. Support importance of avoiding forbidden foods.

Madelyn, a 29-year-old patient recently diagnosed with depression, comes to the mental health clinic complaining of continued difficulty sleeping. One week ago, she was started on a selective serotonin reuptake inhibitor (SSRI), fluoxetine, for her depressive symptoms. When educating Madelyn, your response is guided by the knowledge that: a. SSRIs such as fluoxetine more commonly cause hypersomnolence as opposed to difficulty sleeping. b. The sleep problem is caused by the depression and is unrelated to the medication c. The neurotransmitters involved in sleep and wakefulness are the same neurotransmitters targeted by many psychiatric medications and the problem may be temporary. d. The medication should be discontinued because sleep is the most important element to her recovery.

c. The neurotransmitters involved in sleep and wakefulness are the same neurotransmitters targeted by many psychiatric medications and the problem may be temporary.

Factors that consistently increase the risk for sleep disturbance include a. gender and race. b. diet and exercise. c. alcohol and tobacco. d. income and education.

c. alcohol and tobacco.

A class of medications commonly prescribed for somatic disorders is a. mood stabilizers. b. antidepressants. c. anxiolytics. d. antipsychotics.

c. anxiolytics.

According to current theory, eating disorders: a. are psychotic disorders in which patients experience body dysmorphic disorder. b. are frequently misdiagnosed. c. are possibly influenced by sociocultural factors. d. are rarely comorbid with other mental health disorders.

c. are possibly influenced by sociocultural factors.

A client, who has been receiving antipsychotic medication for 6 weeks, tells the nurse that the hallucinations are nearly gone and that concentration has improved. When the client reports flulike symptoms including a fever and a very sore throat, the nurse should a.suggest that the client take something for her fever and get extra rest. b. advise the physician that the client should be admitted to the hospital. c. arrange for the client to have blood drawn for a white blood cell count. d. consider recommending a change of antipsychotic medication.

c. arrange for the client to have blood drawn for a white blood cell count.

A nurse who is caring for traumatized children of various cultural backgrounds must first a. become familiar with the various cultures. b. gain the children's trust. c. become aware of any personal biases. d. convince the parents that their children require care.

c. become aware of any personal biases.

Victoria is an 8-year-old patient newly diagnosed with attention deficit hyperactivity disorder (ADHD). Based on your knowledge of the diagnosis of ADHD, you know her symptoms of hyperactivity, inattention, and impulsivity have to be apparent: a. in times of severe stress. b. in supervised clinical observations. c. both at home and at school. d. on diagnostic testing tools.

c. both at home and at school.

A child who was physically and sexually abused is at great risk for a. depression. b. suicide attempts. c. bullying and abusing others. d. becoming active in a gang.

c. bullying and abusing others.

Lana is out of surgery and on the medical-surgical unit for recovery. You visit her the day after her surgical procedure. While you are in the room, Lana becomes visibly anxious and short of breath, and she states, "I feel so anxious! Something is wrong!" Your best action is to: a. reassure Lana that she is experiencing normal anxiety and do deep breathing exercises with her. b. use the call light to inquire whether Lana has any prn anxiety medication. c. call for help and assess Lana's vital signs. d. tell Lana you will stay with her until the anxiety subsides.

c. call for help and assess Lana's vital signs.

The diagnosis of impaired intellectual functioning is supported when a child diagnosed with IDD a. can neither brush the teeth nor combing the hair effectively. b. cries uncontrollably when a toy is temporarily missing. c. cannot put together a five-piece jigsaw puzzle. d. has difficulty with the concept of social boundaries.

c. cannot put together a five-piece jigsaw puzzle.

According to the Attachment Theory, relationship disorders are related to trauma associated with a. insufficient food and/or shelter. b. siblings and/or strangers. c. caregivers and/or parents. d. culture and/or religion.

c. caregivers and/or parents.

An example of a somatoform disorder is a. depersonalization. b. dissociative fugue. c. conversion disorder. d. dissociative identity disorder.

c. conversion disorder.

When a child demonstrates a temperament that prompts the mother to say, "She is just so different from me; I just can't seem to connect with her." The nurse will a. suggest that the child's father become her primary caregiver. b. encourage the mother to consider attending parenting classes. c. counsel the mother regarding ways to better bond with her child. d. educate the father regarding signs that the child is being physically abused.

c. counsel the mother regarding ways to better bond with her child.

Syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered: a. dissociative disorders such as dissociative identify disorders. b. physical disorders, not mental disorders. c. culture-bound syndromes that are not dissociative disorders. d. myths, or rumors, because they have not been sufficiently studied to be classified as real.

c. culture-bound syndromes that are not dissociative disorders.

A client who travels often and therefore experiences jet lag regularly reports the use of over-the-counter (OTC) melatonin supplements. The nurse responds by informing the client that a. melatonin is a naturally secreted hormone and thus is a safe supplement. b. research has supported the effectiveness of using melatonin supplements for jet lag. c. currently, no standardized, safe therapeutic dosage range for melatonin supplements has been established. d. hypertension is a common side effect of melatonin supplement therapy.

c. currently, no standardized, safe therapeutic dosage range for melatonin supplements has been established.

A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of a. bipolar II disorder. b. bipolar I disorder. c. cyclothymia. d. seasonal affective disorder.

c. cyclothymia.

A Gulf War veteran is entering treatment for post-traumatic stress disorder. An important facet of assessment is to a. ascertain how long ago the trauma occurred. b. find out if the client uses acting-out behavior. c. determine use of chemical substances for anxiety relief. d. establish whether the client has chronic hypertension related to high anxiety.

c. determine use of chemical substances for anxiety relief.

An appropriate intervention for stage 2 of the staged model of trauma treatment is a. re-enforcing social skills training. b. providing a predictable environment. c. engaging in memory work. d. role-modeling problem-solving skills.

c. engaging in memory work.

Panic attacks in Latin American individuals often involve a. repetitive involuntary actions. b. blushing. c. fear of dying. d. offensive vebalizations.

c. fear of dying.

In contrast to the client diagnosed with anorexia nervosa, the client diagnosed with bulimia usually a. uses greater denial. b. is aware of the eating problem. c. fits more easily into the family. d. appraises his or her body more realistically.

c. fits more easily into the family.

A client diagnosed with disorganized schizophrenia would have greatest difficulty with the nurse a. interacting with a neutral attitude. b. using concrete language. c. giving multistep directions. d. providing nutritional supplements.

c. giving multistep directions.

Tyler is a 31-year-old patient admitted with acute mania. He tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, "I am the only one he trusts, because I am the best!" For documentation purposes you know that this behavior is referred to as: a. unpredictability. b. rapid cycling. c. grandiosity. d. flight of ideas.

c. grandiosity.

A client tells the nurse that when she was younger, she slept 8 to 10 hours nightly, whereas now she sleeps only 6 or 7 hours and has to take a nap each afternoon. The nurse can assess that the client a. has a primary sleep disorder. b. is suffering from sleep apnea. c. has an age-related sleep pattern change. d. is displaying signs of sleep deprivation.

c. has an age-related sleep pattern change.

The nurse's concern about a 12-year-old living in a poor inner city neighborhood becoming involved in gang activity is based on the understanding that this age group a. is often a target of bullies and sexual predators. b. is considered at high risk for drug and alcohol use and abuse. c. has limited decision-making skills and often looks up to older peers. d. lacks intellectual and social skills to select approprate friends.

c. has limited decision-making skills and often looks up to older peers.

During assessment of a client with anorexia nervosa, it is not likely that the nurse would note indications of a. introversion. b. social isolation. c. high self-esteem. d. obsessive-compulsive tendencies.

c. high self-esteem.

Assessment of a client suspected of experiencing bulimia nervosa calls for the nurse to perform a. a range of motion assessment. b. inspection of body cavities. c. inspection of the oral cavity. d. body fat analysis.

c. inspection of the oral cavity.

If a client's record mentions that the client habitually relies on rationalization, the nurse might expect the client to a. make jokes to relieve tension. b. miss appointments. c. justify illogical ideas and feelings. d. behave in ways that are the opposite of his or her feelings.

c. justify illogical ideas and feelings.

A woman suddenly finds she cannot see. She seems unconcerned about her symptom and tells her husband, "Don't worry, dear. Things will all work out." Her attitude is an example of a. regression. b. depersonalization. c. la belle indifference. d. dissociative amnesia.

c. la belle indifference.

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can identify this cognitive distortion as an example of a. self-blame. b. catatonia. c. learned helplessness. d. discounting positive attributes.

c. learned helplessness.

A client reports insomnia and shares that a friend has recommended a nonprescription hormone product that can be purchased at the local health food store. The nurse suspects that the medication is a. a benzodiazepine. b. a tranquilizer. c. melatonin. d. lithium.

c. melatonin

Beck's cognitive theory suggests that the etiology of depression is related to a. sleep abnormalities. b. serotonin circuit dysfunction. c. negative processing of information. d. a belief that one has no control over outcomes.

c. negative processing of information.

A client diagnosed with residual schizophrenia is uninterested in community activities. He lacks initiative, demonstrates both poverty of content of speech and poverty of speech, and seems unable to follow the schedule for taking his antipsychotic medication. The case manager continues to direct his care with the knowledge that his behavior is most likely prompted by a. chronic uncooperativeness. b. personality conflict. c. neural dysfunction. d. dependency needs.

c. neural dysfunction

A young adult applying for a position is mildly tense but eager to begin the interview. This can be assessed as showing a. denial. b. compensation. c. normal anxiety. d. selective inattention.

c. normal anxiety.

When the clinician mentions that a client has anhedonia, the nurse can expect that the client a. has poor retention of recent events. b. experienced a weight loss from anorexia. c. obtains no pleasure from previously enjoyed activities. d. has difficulty with tasks requiring fine motor skills.

c. obtains no pleasure from previously enjoyed activities.

The client reveals to the nurse that, "I'm turned on by little girls, not adult women." The nurse can assess this condition as a. exhibitionism. b. hedonism. c. pedophilia. d. voyeurism.

c. pedophilia.

Hallie, 4 years old, is referred to the outpatient mental health clinic after being in a severe car accident during which her father was driving and her mother died. Her father states she is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. Hallie states to you, "It's my fault because I'm bad." You suspect: a. adjustment disorder. b. dissociative identity disorder. c. posttraumatic stress disorder (PTSD). d. acute stress disorder (ASD).

c. posttraumatic stress disorder (PTSD).

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with a. senile dementia. b. hypertensive crisis. c. psychomotor agitation. d. central serotonin syndrome.

c. psychomotor agitation.

A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating a. projection. b. rationalization. c. reaction formation. d. undoing.

c. reaction formation.

The wife of a client diagnosed with hypochondriasis tells the nurse, "It is so difficult! Whenever we make plans my husband says he is too ill to go. I don't know how much longer I can take it." On the basis of this report, the nurse may wish to explore the nursing diagnosis of a. interrupted family processes. b. decisional conflict. c. risk for caregiver role strain. d. impaired home maintenance.

c. risk for caregiver role strain.

Assessment of the thought processes of a client diagnosed with depression is most likely to reveal a. good memory and concentration. b. delusions of persecution. c. self-deprecatory ideation. d. sexual preoccupation.

c. self-deprecatory ideation.

Biological theorists suggest that the cause of eating disorders may be a. normal weight phobia. b. body image disturbance. c. serotonin imbalance. d. dopamine excess.

c. serotonin imbalance.

A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client's level of anxiety as a. mild. b. moderate. c. severe. d. panic.

c. severe.

It is likely that a client diagnosed with seasonal affective disorder will begin to experience fewer symptoms in the a. fall. b. winter. c. spring. d. summer.

c. spring.

When prescribed lorazepam (Ativan) 1 mg po qid for 1 week for generalized anxiety disorder, the nurse should a. question the physician's order because the dose is excessive. b. explain the long-term nature of benzodiazepine therapy. c. teach the client to limit caffeine intake. d. tell the client to expect mild insomnia.

c. teach the client to limit caffeine intake.

Restraint and seclusion are controversial in children because: a. parents may initiate a lawsuit. b. nursing staff have conflicted feelings leading to ineffectiveness. c. they are psychologically harmful and may be physically harmful. d. staff are untrained in use of restraints in children.

c. they are psychologically harmful and may be physically harmful.

A client diagnosed with PTSD shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that the next medication to be prescribed will be a a. beta blocker. b. barbiturate. c. tricyclic antidepressant (TCA). d. sedative.

c. tricyclic antidepressant (TCA).

You are providing teaching for a patient who has been taking a hypnotic medication to sleep. What education is appropriate? a. "You can use this medication for as long as you would like." b. "It would be better to take an over-the-counter medication instead." c. "Melatonin has been shown to be just as effective as hypnotic medications." d. "Be certain to follow up with your care provider regularly while you take this medication."

d. "Be certain to follow up with your care provider regularly while you take this medication."

Emily asks you what kind of therapy will help her. Your best response, based on current knowledge, is: a. "A combination of antianxiety and antidepressant therapy is the most effective therapy." b. "Aversion therapy is often used because in effect you are punishing yourself by not being able to walk." c. "Modeling will be used; as you see desired behaviors modeled by the therapist you will be able to also achieve the expected outcome." d. "Cognitive behavioral therapy has been shown to consistently provide the best outcome for these types of disorders."

d. "Cognitive behavioral therapy has been shown to consistently provide the best outcome for these types of disorders."

A client reports symptoms suggesting a sexual arousal disorder. The nurse appropriately assesses this client for a possible cause by asking a. "When did the problem first occur?" b. "Is there a specific time of the month when this problem occurs?" c. "Are you allergic to any particular foods?" d. "Do you take any antihistamine medications?"

d. "Do you take any antihistamine medications?"

The nurse appropriately assesses an obese, hypertensive, Type 2 diabetic client when asking, a. "Do you regularly have nightmares?" b. "Is getting to sleep a problem for you?" c. "Do you snooze when you sleep?" d. "How much sleep do you usually get each night?"

d. "How much sleep do you usually get each night?"

What statement by a client would indicate that goals for treatment for a somatization disorder are being achieved? a. "I feel less anxiety than before." b. "My memory is better than it was a month ago." c. "I take my medications just as the physician prescribed." d. "I don't think about my symptoms all the time as I used to."

d. "I don't think about my symptoms all the time as I used to."

Declan is a 26-year-old patient with schizophrenia. He states to you, "My, oh my. My mother is brother. Anytime now it can happen to my mother." Your best response would be: a. "You are having problems with your speech. You need to try harder to be clear." b. "You are confused. I will take you to your room to rest a while." c. "I will get you a prn medication for agitation." d. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

d. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

A nurse is educating a patient about the causes of depression. Which statement lets the nurse know the patient understands the neurobiological theory of depression? a. "My depression is made worse because my marriage is stressful." b. "Sometimes I believe that I can't help myself. That's why I get so depressed." c. "I'm depressed because my parents were depressed." d. "If I take these medications as prescribed, I should start to think clearly and feel energized."

d. "If I take these medications as prescribed, I should start to think clearly and feel energized."

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," an appropriate response for the nurse would be a. "You are safe here. This is a locked unit, and no one can get in." b. "I do not believe I understand the word volmers. Tell me more about them." c. "Why do you think someone or something is going to harm you?" d. "It must be frightening to think something is going to harm you."

d. "It must be frightening to think something is going to harm you."

Jamie, age 24, has been diagnosed with a dissociative disorder following a traumatic event. Jamie's mother asks you, "Does this mean my daughter is now crazy?" Your best response would be: a. "People with dissociative disorders are out of touch with reality, so in that way, your daughter is now mentally ill. Don't worry. Treatment is available." b. "Jamie will most likely need long-term intensive in patient treatment to deal with her traumatic memories as well as to work through her delusions." c. "Most mental health providers are skeptical about dissociative disorders and aren't sure they truly exist. Jamie may be making up her symptoms as a cry for help." d. "Jamie is dealing with the anxiety associated with the trauma by separating herself from it. With treatment she can get back to her previous level of functioning."

d. "Jamie is dealing with the anxiety associated with the trauma by separating herself from it. With treatment she can get back to her previous level of functioning."

As you are talking with Ellie, she begins to cry and states, "I can't keep going like this! I work in a bank and if I can't function correctly I'll lose my job. I just don't think I'll get better." A therapeutic response would be: a. "Don't worry! I'm sure with treatment everything will get better." b. "You are not alone. Many people who come for sleep studies are going through the same thing." c. "You seem so sad. May I ask if something else is troubling you?" d. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work."

d. "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work."

Medications to treat insomnia are usually prescribed for no longer than a. 1 to 2 days. b. 1 to 2 months. c. 3 weeks. d. 2 weeks.

d. 2 weeks.

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? a. A 13-year-old male b. A 10-year-old female c. A 7-year-old male d. A 4-year-old female

d. A 4-year-old female

A 12-year-old male patient diagnosed with Tourette's disorder is visiting his provider. The provider tells you to provide education for the patient and his mother because the provider is starting the patient on medication. Based on your knowledge of medications approved to treat this disorder, you will prepare medication teaching on which class of medication? a. Mood stabilizers b. Antianxiety agents c. Anticholinesterase inhibitors d. Antipsychotics

d. Antipsychotics

Your patient, Erin, is a 16-year-old patient newly diagnosed with anorexia. Her provider is starting her on medication to reduce compulsive behaviors regarding food and resistance to weight gain. You prepare teaching on which class of medication that may help these specific symptoms in eating disorders? a. Mood stabilizers b. Antidepressants c. Anxiolytics d. Atypical antipsychotics

d. Atypical antipsychotics

A 7-year-old male without any other diagnosed problem engages in jaw clenching and rocking back and forth. Which condition should the nurse anticipate? a. Attention deficit hyperactivity disorder b. Tourette's disorder c. Stereotypic movement disorder d. Autism spectrum disorder

d. Autism spectrum disorder

Which statement about somatoform disorders is true? a. An organic basis exists for each group of disorders. b. Nurses perceive clients with these disorders as easy to care for. c. No relation exists between these disorders and early childhood loss or trauma. d. Clients lack awareness of the relations among symptoms, anxiety, and conflicts.

d. Clients lack awareness of the relations among symptoms, anxiety, and conflicts. Correct

Tyler is being discharged home to his family. Which of the following is important teaching to include for the patient and the family to recognize possible signs of impending mania? a. Increased appetite b. Decreased social interaction c. Increased attention to bodily functions d. Decreased sleep

d. Decreased sleep

Which medication would the nurse most likely include when educating the parents of a child diagnosed with attention deficit hyperactivity disorder? a. Buspirone (Buspar) b. Haloperidol (Haldol) c. Clomipramine (Anafranil) d. Methylphenidate (Ritalin)

d. Methylphenidate (Ritalin)

Which medication is FDA approved for treatment of anxiety in children? a. Lorazepam (benzodiazepine) b. Fluoxetine (selective serotonin reuptake inhibitor) c. Clomipramine (tricyclic antidepressant) d. None of the above

d. None of the above

An older adult client is reporting symptomatology that suggests REM sleep behavior disorder (RSBD). The nurse is correct in recognizing that this client is at risk for developing a. lymphoma. b. hypertension. c. acute renal failure. d. Parkinson's disease.

d. Parkinson's disease.

Which behavior by a client would not support a diagnosis of somatoform disorder? a. Attention seeking from significant others b. Acquiring financial gain from a disability plan c. Avoidance of certain unpleasant activities d. Performing activities of daily living unassisted

d. Performing activities of daily living unassisted

The information that is least relevant when assessing a patient a suspected somatization disorder is: a. Understanding coping mechanisms b. Results of diagnostic workups c. Limitations in activities of daily living d. Potential for violence

d. Potential for violence

Which behavior would be characteristic of an individual who is displacing anger? a. Lying b. Stealing c. Slapping d. Procrastinating

d. Procrastinating

The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, "I hear voices of aliens trying to contact me." The nurse should recognize this presentation as which type of major depressive disorder (major depression)? a. Seasonal Affective Disorder b. Dysthymic Disorder c. Premenstraul Dysphoric Disorder d. Psychotic

d. Psychotic

Which nursing intervention would be helpful when caring for a client diagnosed with an anxiety disorder? a. Express mild amusement over symptoms. b. Arrange for client to spend time away from others. c. Advise client to minimize exercise to conserve endorphins. d. Reinforce use of positive self-talk to change negative assumptions.

d. Reinforce use of positive self-talk to change negative assumptions.

Lance asks you what medication is usually used for premature ejaculation. You educate him regarding a class of medications that are used for treatment but have to be monitored for the possibility of dosage reduction or change related to the possibility of causing sexual side effects. Which of the following is the class of medications you are educating Lance about? a. MAO inhibitors b. Tricyclic antidepressants c. Atypical antipsychotics d. SSRI antidepressants

d. SSRI antidepressants

You are caring for Aaron, a 38-year-old patient diagnosed with somatic symptom disorder. When interacting with you, Aaron continues to focus on his severe headaches. In planning care for Aaron, which of the following interventions would be appropriate? a. Call for a family meeting with Aaron in attendance to confront Aaron regarding his diagnosis b. Educate Aaron on alternative therapies to deal with pain c. Improve reality testing by telling Aaron that you do not believe that the headaches are real. d. Shift focus from Aaron's somatic concerns to feelings and effective coping skills.

d. Shift focus from Aaron's somatic concerns to feelings and effective coping skills.

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years and Tara at 31 years. Based on your knowledge of early and late onset of schizophrenia, which of the following is true? a. Tara and Aaron have the same expectation of a poor long-term prognosis. b. Tara will experience more positive signs of schizophrenia such as hallucinations. c. Aaron will be more likely to hold a job and live a productive life. d. Tara has a better chance for positive outcomes because of later onset.

d. Tara has a better chance for positive outcomes because of later onset.

Which side effect of antipsychotic medication is generally nonreversible? a. Anticholinergic effects b. Pseudoparkinsonism c. Dystonic reaction d. Tardive dyskinesia

d. Tardive dyskinesia

A patient states that he only needs 6 hours of sleep per night to feel rested. How should the nurse interpret this statement? a. The patient is not sleeping enough b. The patient is sleeping too much c. The patient is not getting enough REM sleep d. The patient is sleeping according to his own body's needs.

d. The patient is sleeping according to his own body's needs.

Which statement about structural dissociation of the personality is true? a. An organic basis exists for this type of disorder. b. Nurses perceive clients with this disorder as easy to care for. c. No known link exists between this disorder and early childhood loss or trauma. d. This disorder results in a split in the personality causing a lack of integration.

d. This disorder results in a split in the personality causing a lack of integration.

You are caring for Conner, an 8-year-old boy who has been diagnosed with reactive attachment disorder. Which of the following nursing outcomes would be the most appropriate to achieve? a. Increases ability to self-control and decreases impulsive behaviors. b. Avoids situations that trigger conflicts. c. Expresses complex thoughts. d. Writes or draws feelings in a journal.

d. Writes or draws feelings in a journal.

The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of a. standard antipsychotic medication. b. tricyclic antidepressant medication. c. anticholinergic medication. d. a short-acting benzodiazepine medication.

d. a short-acting benzodiazepine medication.

Sasha's roommate Kate was admitted with major depression and suicidal ideation with a plan to overdose. Kate is preparing for discharge and asks you, "Why did Dr. Travis give me a prescription for only 7 days of amitriptyline?" Your response is based on the knowledge that: a. amitriptyline (Elavil) is very expensive, so the patient may have to buy fewer at a time. b. Dr. Travis is going to see how Kate responds to the first week of medication to evaluate its effectiveness. c. Dr. Travis wants to see whether any minor side effects occur within the first week of administration. d. amitriptyline (Elavil) is lethal in overdose.

d. amitriptyline (Elavil) is lethal in overdose.

Dysthymia cannot be diagnosed unless it has existed for a. at least 3 months. b. at least 6 months. c. at least 1 year. d. at least 2 years.

d. at least 2 years.

The type of altered perception most commonly experienced by clients with schizophrenia is a. delusions. b. illusions. c. tactile hallucinations. d. auditory hallucinations.

d. auditory hallucinations.

In somatization disorders, it is important for the nurse to employ holistic strategies. This can be defined as: a. utilizing many different therapeutic strategies or modalities for enhanced coping. b. involving every member of the family as well as the patient in treatment. c. incorporating spirituality and religion into treatment. d. considering all dimensions of the patient, including biological, psychological, and sociocultural.

d. considering all dimensions of the patient, including biological, psychological, and sociocultural.

Schizophrenia is best characterized as a. split personality. b. multiple personalities. c. ambivalent personality. d. deteriorating personality.

d. deteriorating personality.

A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions that she will take the medication along with the St. John's wort she uses daily. The nurse should a. agree that taking the drugs at the same time will help her remember them daily. b. caution the client to drink several glasses of water daily. c. suggest that the client also use a sun lamp daily. d. explain the high possibility of an adverse reaction.

d. explain the high possibility of an adverse reaction.

A subjective symptom the nurse would expect to note during assessment of a client with anorexia nervosa is a. lanugo. b. hypotension. c. 25-lb weight loss. d. fear of gaining weight.

d. fear of gaining weight.

A symptom commonly associated with panic attacks is a. obsessions. b. apathy. c. fever. d. fear of impending doom.

d. fear of impending doom.

A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." The nurse would make the assessment that the client is displaying a. flight of ideas. b. distractibility. c. limit testing. d. grandiosity.

d. grandiosity.

An adjustment in the medication dosage prescribed for a child diagnosed with attention deficit hyperactivity disorder (ADHD) is most likely when the child a. engages in strenuous exercise. b. is challenged to learn new cognitive material. c. experiences a loss. d. has a growth spurt.

d. has a growth spurt.

The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when the client a. weighs 10% below ideal body weight. b. has a serum potassium level of 3 mEq/L or greater. c. has a heart rate less than 60 beats/min. d. has systolic blood pressure less than 70 mm Hg.

d. has systolic blood pressure less than 70 mm Hg.

When caring for a client demonstrating the inability to provide effective self-care, the nurse a. identifies the level of self-care the client is willing to perform and sets expectations accordingly. b. initially sets only minimal self-care expectations for the client. c. attends to all self-care needs until the client indicates a willingness to perform care independently. d. identifies the client's highest level of self-care and states reasonable expectations to the client.

d. identifies the client's highest level of self-care and states reasonable expectations to the client.

A client who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds eats one tiny meal daily and engages in a rigorous exercise program. The nursing diagnosis for this client would be a. death anxiety. b. ineffective denial. c. disturbed sensory perception. d. imbalanced nutrition: less than body requirements.

d. imbalanced nutrition: less than body requirements.

The major distinction between fear and anxiety is that fear a. is a universal experience; anxiety is neurotic. b. enables constructive action; anxiety is dysfunctional. c. is a psychological experience; anxiety is a physiological experience. d. is a response to a specific danger; anxiety is a response to an unknown danger.

d. is a response to a specific danger; anxiety is a response to an unknown danger.

When preparing to assess a 4-year-old child to help rule out a neurodevelopmental disorder, the nurse bases interventions on the understanding that a. children of that age are very resilient. b. age make these children poor interviewees. c. poor cooperation is typical at that age. d. language skills are limited at that age.

d. language skills are limited at that age.

You are providing teaching to Lana, a preoperative patient just before surgery. She is becoming more and more anxious as you talk. She begins to complain of dizziness and heart pounding, and she is trembling. She seems confused. Your best response is to: a. reinforce the preoperative teaching by restating it slowly. b. have Lana read the teaching materials instead of verbal instruction. c. have a family member read the preoperative materials to Lana. d. not attempt any teaching at this time.

d. not attempt any teaching at this time.

Delusionary thinking is a characteristic of a. chronic anxiety. b. acute anxiety. c. severe anxiety. d. panic level anxiety.

d. panic level anxiety.

A client is running from chair to chair in the solarium. He is wide-eyed and keeps repeating, "They are coming! They are coming!" He neither follows staff direction nor responds to verbal efforts to calm him. The level of anxiety can be assessed as a. mild. b. moderate. c. severe. d. panic.

d. panic.

When a client experiences four or more mood episodes in a 12-month period, the client is said to be a. dyssynchronous. b. incongruent. c. cyclothymic. d. rapid cycling.

d. rapid cycling.

Dissociative identity disorder is characterized by a. the inability to recall important information. b. sudden, unexpected travel away from home and inability to remember the past. c. the existence of two or more subpersonalities, each with its own patterns of thinking. d. recurring feelings of detachment from one's body or mental processes.

d. recurring feelings of detachment from one's body or mental processes.

A client has reached the stable plateau phase of schizophrenia. An appropriate clinical focus for planning would be a. safety and crisis intervention. b. acute symptom stabilization. c. stress and vulnerability assessment. d. social, vocational, and self-care skills.

d. social, vocational, and self-care skills.

When providing sleep hygiene information to a client reporting difficulty falling asleep, the nurse includes a. drinking a small amount of alcohol to relax just before bedtime. b. taking a short nap after lunch whenever possible. c. keeping the bedroom warm to induce coziness. d. taking a 20-minute walk after dinner.

d. taking a 20-minute walk after dinner.

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. The nurse explains that a. children this age usually have imaginary friends. b. it is nothing to worry about unless the child starts to socially isolate. c. the child needs more of their one-on-one attention. d. the imaginary friend is a coping mechanism the child is using.

d. the imaginary friend is a coping mechanism the child is using.

When the wife of a manic client asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on the knowledge that a. no research exists to suggest genetic transmission. b. much depends on the socioeconomic class of the individuals. c. highly creative people tend toward development of the disorder. d. the rate of bipolar disorder is higher in relatives of people with bipolar disorder.

d. the rate of bipolar disorder is higher in relatives of people with bipolar disorder.

A depressed client tells the nurse he is in the "acute phase" of his treatment for depression. The nurse recognizes that the client has been in treatment a. for more than 4 months. b. that is directed toward relapse prevention. c. that focuses on prevention of future depression. d. to reduce depressive symptoms.

d. to reduce depressive symptoms.

A 10-year-old who is frequently disruptive in the classroom, begins to fidget in her chair and then moves on to disruptive behavior. A possible technique for managing this sort of disruptive behavior is a. therapeutic holding. b. seclusion. c. quiet room. d. touch control.

d. touch control.

A client explains that he is not homosexual but that he prefers to dress in feminine clothing. This is a characteristic of a. fetishism. b. exhibitionism. c. voyeurism. d. transvestism.

d. transvestism.

A variety of medications are used in the treatment of severe anxiety disorders. Which class of medication used to treat anxiety is partially addictive? a. Selective serotonin reuptake inhibitors (SSRIs) b. Beta-blockers c. Antihistamines d. Buspirone e. Benzodiazepines

e. Benzodiazepines

Working to help the client view an occurrence in a more positive light is called a. flooding. b. desensitization. d. response prevention. e. cognitive restructuring. Correct

e. cognitive restructuring.

The primary purpose of performing a physical examination before beginning treatment for any anxiety disorder is to a. cognitive restructuring. b. protect the nurse legally. c. establish the nursing diagnoses of priority. d. obtain information about the client's psychosocial background. e. determine whether the anxiety is primary or secondary in origin.

e. determine whether the anxiety is primary or secondary in origin.

The nurse educator is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (4) restrictive: a. Allowing the patient to sit in the sensory room b. Placing the patient in physical restraints c. Placing the patient in a locked seclusion room d. offering a PRN medication by mouth

1. Allowing the patient to sit in the sensory room 2. offering a PRN medication by mouth 3. Placing the patient in a locked seclusion room 4. Placing the patient in physical restraints

While on an inpatient unit, you are caring for newly admitted Alyssa, a 16-year-old diagnosed with anorexia nervosa. Number the following nursing interventions in order of priority: a. ___ Initiate a therapeutic relationship b. ___ Promote caloric consumption c. ___ Assess for suicidal ideation d. ___ Review accomplishments made during treatment e. ___ Explore feelings of underlying anxiety and low self-esteem

1. Initiate a therapeutic relationship 2. Assess for suicidal ideation 3. Promote caloric consumption 4. Explore feelings of underlying anxiety and low self-esteem 5. Review accomplishments made during treatment

Tyler's nursing care plan has several nursing diagnoses listed. Match the nursing diagnosis to the level of priority (1 to 4): a. Knowledge, deficient b. Nonadherence c. Risk for injury d. Self-care deficit, bathing and hygiene

1. Risk for injury 2. Self-care deficit, bathing and hygiene 3. Knowledge, deficient 4. Nonadherence