Final

A homeless client comes to an emergency department reporting cough, night sweats, weight loss, and blood-tinged sputum. What disease that has recently become more prevalent among the homeless community should a nurse suspect? A. Meningitis B. Tuberculosis C. Encephalopathy D. Mononucleosis

B

The nurse is reviewing STAT laboratory data of a client presenting in the ED. What is the minimum blood alcohol level at which should the nurse expects intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

B

Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? A. Schizophrenia B. Major depressive disorder C. Phobic disorder D. Dependent personality disorder

B

Which of the following are symptoms of inhalant intoxication? Select all that apply. A. Bradycardia B. Euphoria C. Hyperactive reflexes D. Ataxia E. Nystagmus

BDE

Bob Taylor's home was recently destroyed in a fire. Margaret Smith is 35 years old and has just learned that she must have a hysterectomy. Which scenario will most likely trigger a grief response? A. Taylor's home destroyed by fire. B. Smith's pending hysterectomy. C. Neither scenario by itself could trigger the grief response. D. Both scenarios could trigger individual grief responses.

D

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an ED by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When will the nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted

A

A client in the inpatient unit tells a student nurse, "My life has no purpose. I can't think about living another day, but please don't tell anyone about the way I feel. I know you are obligated to protect my confidentiality." Which is the most appropriate reply by the student nurse? A. "The treatment team is composed of many specialists who are working to improve your ability to function. Sharing this information with the team is critical to your care." B. "Let's discuss steps that will resolve negative lifestyle choices that may increase your suicidal risk." C. "You seem to be preoccupied with self. You should concentrate on hope for the future." D. "This information is secure with me because of client confidentiality."

A

A client is admitted for alcohol detoxification. During detoxification, which symptoms the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

A

A client reports during his visit to the mental health clinic that he is distressed by repetitive sexual fantasies that involve humiliating his sexual partner. This would most appropriately be assessed as what type of disorder? A. Paraphilic disorder B. Obsessive-compulsive disorder C. Erectile disorder D. Hypoactive sexual desire disorder

A

A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to the nurse that the student is handling this situation in a healthy manner? A. "I know that it was not my fault." B. "My boyfriend has trouble controlling his sexual urges." C. "If I don't put myself in a dating situation, I won't be at risk." D. "Next time I will think twice about wearing a sexy dress."

A

A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. "Taking multiple medications may lead to adverse interactions or toxicity." B. "Age-related cognitive changes may lead to alterations in mental status." C. "Lack of rigorous exercise may lead to decreased cerebral blood flow." D. "Decreased social interaction may lead to profound isolation and psychosis."

A

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy

A

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

A

A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's disease (AD)?" Which is the appropriate instructor reply? A. "Donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." B. "Donepezil (Aricept) encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." C. "Donepezil (Aricept) delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the disease." D. "Donepezil (Aricept) encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."

A

A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? A. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." B. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. C. "People with dissociative disorders typically have strong egos." D. "There is clear and convincing evidence of a familial predisposition to this disorder."

A

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. "Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not." B. "Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not." C. "Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not." D. "Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not."

A

A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which response indicates that the student has evaluated the situation appropriately? A. "This child's behavior must be evaluated according to developmental norms." B. "This child has symptoms of ADHD." C. "This child has symptoms of the early stages of autistic disorder." D. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

A

After an adolescent diagnosed with attention-deficit/hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, the nurse notes that the adolescent loses 10 pounds in a 2-month period. Which is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

A

After found in an alley, Theresa was taken to a nearby emergency room. Upon arrival, police notified the nurse that Theresa was a suspected rape victim, which Theresa confirmed. The doctor orders a rape kit to retrieve any DNA that may still be present on or in the victim. What is the most appropriate nursing intervention? A. Try to have as few people as possible collecting immediate evidence. B. Offer to call the victim's pastor or spiritual advisor. C. Provide a variety of support resources for survivors of sexual assault. D. Clean the victim's wounds and administer sedative medications as ordered.

A

An adolescent client who was diagnosed with Conduct Disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. Which indicates the nurse's understanding of conduct disorder related to this client's situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

A

Dashawn likes to ride a crowded subway train and brush up against an unsuspecting woman and fondle her breast with his hands to derive sexual pleasure. Dashawn has what disorder? A. Frotteuristic Disorder B. Gender Dysphoria C. Hypoactive Sexual Drive Disorder D. Unspecified Sexual Disorder

A

Mary is seeing her family physician for a routine checkup and mentions to the nurse that her husband just returned from active duty in the military. He was deployed to Iraq for the last 18 months, and Mary says she is very excited that they will finally be able to pick up where they left off. The nurse decides to ask more questions about their marital relationship in this post deployment period. Which is the best rationale for including these assessment questions? A. The post deployment period is often the most difficult time for veterans and spouses to negotiate. B. All veterans experience some PTSD and are unable to return to previous relationship patterns. C. Denial about the impact of combat experiences is common among military spouses. D. Mary is most likely being abused by her husband and is covering this up.

A

Paula's husband returned from active duty 1 month ago, and Paula is now seeing a counselor for relational conflict in her marriage. She tells the counselor that she thinks her husband "can't love anything as much as he loves the military" and that "he acts like he can't wait to be redeployed." Which of these might be contributing to her husband's behavior? A. Military mission is advanced as the highest priority. B. Marriage is discouraged in the military. C. Redeployment is considered the highest honor. D. People who choose a military lifestyle often have asocial personality traits.

A

Providing nursing education on drug abuse to a high-school class is an example of which level of preventive care? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Primary intervention

A

The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which of these responses by the nurse is evidence based? A. "Most symptoms of conversion disorder resolve within a few weeks." B. "Typically, people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." C. "The only people who recover are those who develop conversion disorder symptoms without a precipitating stressful event." D. "Technically, he could walk now since he is intentionally feigning paralysis."

A

The nurse observes dental deterioration when assessing a client diagnosed with Bulimia Nervosa. What explains this assessment finding? A. Emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

A

What is the main goal of crisis intervention for sexual assault? A. Help survivors return to their previous lifestyle as quickly as possible. B. Determine the appropriate long-term assistance needed. C. Treat any physical symptoms that exist resulting from the assault. D. Focus on the rape incident alone.

A

When Beverly told her sister Liz about the repeated episodes of abuse she'd experienced, her sister replied, "If you leave him, how will you be able to pay your bills?" Liz's reply supports which notion? A. Battered women may be encouraged by their social network to remain in the abusive relationship. B. Women who are battered often take blame for their situations. C. The sisters were victims of child abuse. D. Family members rarely believe that intimate partner violence is occurring.

A

When planning care for a client, which medication classification should the nurse recognize as effective in the treatment of Tourette's disorder? A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor (MAOI) medications

A

Which statement by an emergency department nurse indicates accurate knowledge of domestic violence? A. "Power and control are central to the dynamic of domestic violence." B. "Poor communication and social isolation are central to the dynamic of domestic violence." C. "Erratic relationships and vulnerability are central to the dynamic of domestic violence." D. "Emotional injury and learned helplessness are central to the dynamic of domestic violence."

A

Why would a nurse establish goals for a client diagnosed with ADHD, presenting with low frustration tolerance and short attention span that allows the client to complete part of the task, rewarding each step-completion with a break for physical activity? A. Short-term goals are not so overwhelming with a short attention span. B. Repetition of instructions helps to determine the client's level of comprehension. C. This encourages the client to perform independently while providing a feeling of security. D. The client lacks the ability to assimilate information that is complicated or has abstract meaning.

A

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? Select all that apply. A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

AB

John is treated for PTSD symptoms, which began shortly after his retirement from the military. He has had nightmares, flashbacks of traumatic events from combat, and episodes of acute anxiety. His wife is asking the nurse how he could be developing PTSD at this time when he hasn't been in a combat situation for over 10 years. Which of these teaching points are evidence-based information to share with John's wife? Select all that apply. A. Retirement has been identified as a common precipitating factor for PTSD. B. PTSD symptoms may develop at any time after a trauma. C. PTSD is not the appropriate diagnosis, according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), unless the trauma occurred greater than 5 years ago. D. This is probably not PTSD, but rather a brief adjustment reaction to retirement.

AB

Nancy is a 42-year-old, lesbian, premenopausal woman who visits her gynecologist for an annual examination. The nurse visits with Nancy before the examination and informs her of the symptoms of menopause that she may begin to experience. Which symptoms should the nurse teach Nancy? Select all that apply. A. Insomnia B. Heart palpitations C. Depression D. Vaginal discharge

ABC

Which evidence-based statement regarding adolescent coitus is accurate? Select all that apply. A. More adolescents are engaging in premarital intercourse. B. The incidence of premarital intercourse for girls has increased. C. The average age of first intercourse has decreased. D. The majority of adolescent boys do not use condoms during intercourse.

ABC

Which of the following characteristics should a nurse identify as normal in the development of human sexuality for an 11-year-old child? Select all that apply. A. The child experiments with masturbation. B. The child may experience homosexual play. C. The child shows little interest in the opposite sex. D. The child shows little concern about physical attractiveness. E. The child is unlikely to want to undress in front of others.

ABE

A nursing instructor is teaching a class on sexuality that includes information about gender dysphoria. Which statement made by a student indicates an understanding of the teaching? Select all that apply. A. "Gender identity does not dictate to whom one is attracted." B. "Transgender is caused by an increase in female hormones." C. "The majority of transgender individuals are men who wish to reassign to female gender." D. "Impaired family dynamics lead to gender dysphoria."

AC

Silawa is a middle-aged woman who has a total hysterectomy 3 months ago. She has a medical history of depression, diabetes mellitus, peptic ulcer disease, and asthma. Silawa's daily medications include Citalopram (Celexa), Metformin, Omeprazole (Prilosec), and Montelukast (Singulair). Silawa tells the nurse that she has been unable to achieve orgasm once she resumed sexual activity after her hysterectomy. She states that she's never has this problem before. Which factors found in Silawa's medical history may be the cause of her orgasmic disorder? Select all that apply. A. Diagnosis of depression B. Diagnosis of asthma C. Diagnosis of diabetes mellitus D. Citalopram (Celexa) medication regimen E. Omeprazole (Prilosec) medication regimen F. Montelukast (Singulair) medication regimen

ACD

Jane has begun treatment for PTSD with symptoms of depression. The nurse is reviewing the physician's orders. Which of these are evidence-based modalities for initial treatment of Jane's illnesses? Select all that apply. A. Acupuncture B. Electroconvulsive therapy (ECT) C. Sertraline (Zoloft) D. Cognitive behavior therapy (CBT) E. Propranolol (Inderal)

ACDE

A child has been diagnosed with Autism Spectrum Disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? A. Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." B. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." C. "Research has shown that the mother appears to play a greater role in the development of this disorder than does the father." D. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?"

B

A child has been recently diagnosed with Mild Intellectual Disability (ID). Which information about this diagnosis should the nurse include when teaching the child's mother? A. Children with mild ID need constant supervision. B. Children with mild ID develop academic skills up to a sixth-grade level. C. Children with mild ID appear different from their peers. D. Children with mild ID have significant sensory-motor impairment.

B

A client diagnosed with cluster C traits sits alone and ignores other's attempts to converse. When asked to join a group, the client states, "No, thanks." In this situation, which initial nursing diagnosis should the nurse assign? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

B

A client is brought to an emergency department after being violently raped. Which nursing action is most appropriate? A. Discourage the client from discussing the event, as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the client's description of the event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.

B

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

B

A community health nurse is teaching a class to expectant parents. All participants lack infant care knowledge. A student nurse asks, "If you had to assign a nursing diagnosis to this group, what would it be?" What is the best nursing reply? A. "I would assign the nursing diagnosis of cognitive deficit." B. "I would assign the nursing diagnosis of knowledge deficit." C. "I would assign the nursing diagnosis of altered family processes." D. "I would assign the nursing diagnosis of risk for caregiver role strain."

B

A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? A. "I'm glad we discussed this. We'll excuse him from the activity groups." B. "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." C. "The groups are optional. Only clients at high functioning levels would benefit." D. "If your father doesn't go to these activity groups, he will be at high risk for developing dementia."

B

A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? A. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." B. "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." C. "Reminiscence therapy is a social group where members chat about past events and future plans." D. "Reminiscence therapy encourages members to share positive memories of significant life transitions."

B

A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

B

A preschool child is admitted to a psychiatric unit with a diagnosis of Autism Spectrum Disorder. To help the child feel more secure on the unit, which intervention should the nurse include in this client's plan of care? A. Encourage and reward peer contact. B. Provide consistent caregivers. C. Provide a variety of safe daily activities. D. Maintain close physical contact throughout the day.

B

An anorexic client states to the nurse, "My father has recently moved back to town." Since that time, the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated, and lives alone. Which should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood bulimia

B

As a domestic violence nurse specialist, you are asked to testify in a court case involving intimate partner abuse. The defense attorney asks, "When Mr. and Mrs. Smith came to the emergency room several people were around, yet Mrs. Smith still did not say that Mr. Smith hit her. With all those people around, why didn't Mrs. Smith accuse her husband then?" What is the most likely and most appropriate rationale? A. Abuse victims are not likely to accuse spouses without photographic evidence. B. Abuse victims who are accompanied by the person who battered them are not likely to be truthful about the cause of the injuries. C. Abuse victims are not always aware of resources available to them. D. Abuse victims often lie about their injuries because they are afraid they will be killed or their children will be harmed.

B

During an assessment interview, a client diagnosed with Antisocial Personality Disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. "You are very disrespectful. You need to learn to control yourself." B. "I understand that you are angry, but this behavior will not be tolerated." C. "What behaviors could you modify to improve this situation?" D. "What antipersonality disorder medications have helped you in the past?"

B

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. "Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions." B. "Family intervention and support are important in your child's recovery." C. "Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support." D. "Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed."

B

The nurse is assessing a client diagnosed with pedophilic disorder. What would differentiate this sexual disorder from a sexual dysfunction? A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

B

The nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, "I'm planning an elaborate wake and funeral." According to George Engel, Which purpose do these rituals serve? A. To delay the recovery process initiated by the loss of the client's spouse B. To facilitate the acceptance of the loss of the client's spouse C. To avoid dealing with grief associated with the loss of the client's spouse D. To eliminate emotional pain related to the loss of the client's spouse

B

The nurse is counseling a client diagnosed with Gender Dysphoria. Which characteristic would differentiate this disorder from Transvestic Disorder? A. Clients diagnosed with Transvestic Disorder are dissatisfied with their gender, whereas clients diagnosed with Gender Dysphoria are not. B. Clients diagnosed with Gender Dysphoria are dissatisfied with their gender, whereas clients diagnosed with Transvestic Disorder are not. C. Clients diagnosed with Gender Dysphoria never engage in cross-dressing, whereas clients diagnosed with Transvestic Disorder do. D. Clients diagnosed with Transvestic Disorder never engage in cross-dressing, whereas clients diagnosed with Gender Dysphoria do.

B

The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis does.

B

The nurse working with a client diagnosed with Bulimia Nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

B

Which behavioral approach should the nurse utilize when caring for children diagnosed with a disruptive behavior disorder? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

B

Which finding is the nurse most likely to assess in a child diagnosed with Separation Anxiety Disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's mother and father have an inconsistent parenting style.

B

Which nursing intervention is appropriate when caring for clients diagnosed with either Anorexia Nervosa or Bulimia Nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

B

Which nursing intervention related to self-care is most appropriate for a teenager diagnosed with Moderate Intellectual Disability? A. Meeting all of the client's self-care needs to avoid injury B. Providing simple directions and praising client's independent self-care efforts C. Avoiding interference with the client's self-care efforts in order to promote autonomy D. Encouraging family to meet the client's self-care needs to promote bonding

B

In 1991, the U.S. Congress passed the Patient Self-Determination Act, which requires which of the following? Select all that apply. A. States must define how and under what circumstances individuals can refuse life-sustaining medical interventions. B. All health-care facilities must advise clients of their rights to refuse treatment. C. Advance directives are made available to patients on admission. D. Records of whether a client has an advanced directive or designated health-care proxy exist.

BCD

A nursing instructor is teaching about the various categories of paraphilic disorders. Which of the following categories are correctly matched with expected behaviors? Select all that apply. A. Exhibitionistic disorder: Mary models lingerie for a company that specializes in home parties. B. Voyeuristic disorder: John is arrested for peering in a neighbor's bathroom window. C. Frotteuristic disorder: Peter enjoys subway rush-hour female contact that results in arousal. D. Pedophilic disorder: George can experience an orgasm by holding and feeling shoes. E. Fetishistic disorder: Henry masturbates into his wife's silk panties.

BCE

A child diagnosed with ADHD is having difficulty completing homework assignments. Which information should the nurse include when teaching the parents about task performance improvement? A. The parents should isolate the child when completing homework to improve focus. B. The parents should withhold privileges if homework is not completed within a 2-hour period. C. The parents should divide the homework task into smaller steps and provide an activity break. D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework.

C

A client diagnosed with Paranoid Personality Disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the client's paranoid perceptions.

C

A client diagnosed with Somatic Symptom Disorder is most likely to exhibit which personality disorder characteristics? A. Uses "splitting" and manipulation in relationships B. Is socially irresponsible, exploitative, and guiltless and disregards rights of others C. Expresses heightened emotionality, seductiveness, and strong dependency needs D. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange

C

A client diagnosed with a NCD is exhibiting behavioral problems every day. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should the nurse implement first? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

C

A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should the nurse recognize? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

C

A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurse's first priority? A. Contact the client's psychiatrist. B. Avoid addressing her attention-seeking behavior. C. Lead the client back to her room and assist her to choose appropriate clothing. D. Restrict client to room until visiting hours are over.

C

A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should the nurse associate with these assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder (HPD) D. Manic personality disorder

C

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Lorcaserin (Belviq) D. Pemoline (Cylert)

C

A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care? A. Teaching an adolescent about pregnancy prevention B. Teaching an elderly client the reportable side effects of a newly prescribed neuroleptic medication C. Teaching a client with schizophrenia to cook meals, make a grocery list, and establish a budget D. Teaching a client about his or her new diagnosis of bipolar disorder

C

A nursing student asks an emergency department nurse, "Why does a rapist use a weapon during the act of rape?" Which nursing reply is most accurate? A. "A weapon is used to increase the victimizer's security." B. "A weapon is used to inflict physical harm." C. "A weapon is used to terrorize and subdue the victim." D. "A weapon is used to mirror learned family behavior patterns."

C

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the ED experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. The nurse recognizes that the client's symptoms indicate which of the following? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

C

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid that next time he might kill me." Which is the most appropriate nursing reply? A. "Leopards don't change their spots, and neither will he." B. "There are things you can do to prevent him from losing control." C. "Let's talk about your options so that you don't have to go home." D. "Why don't we call the police so that they can confront your husband with his behavior?"

C

An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen? A. Altered cortical and intellectual functioning B. Altered respiratory and gastrointestinal functioning C. Altered liver and kidney functioning D. Altered endocrine and immune system functioning

C

An inpatient client is newly diagnosed with Dissociative Identity Disorder (DID) stemming from severe childhood sexual abuse. Which is the priority nursing intervention? A. Encourage exploration of sexual abuse. B. Encourage guided imagery. C. Establish trust and rapport. D. Administer antianxiety medications.

C

Carly has been diagnosed with Somatic Symptom Disorder. As the nurse is talking with Carly and her family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? A. The family agrees that Carly began having physical symptoms after she lost her job. B. Carly states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. C. Carly's mother reports that someone from the family stays with Carly each night because the physical symptoms are incapacitating. D. Carly states she noticed feeling hotter than usual the last time she had a headache.

C

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

C

In the emergency department, a client who was raped appears calm and exhibits a blunt affect. The client answers the nurse's questions in a monotone using single words. Which indicates the nurse interpretation of this client's responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

C

Joshua, a 15-year-old whose father has been suffering from PTSD since returning from combat, is now seeing a counselor himself with reports of "flashbacks" that are similar to his father's symptoms. Which of the following interpretations of Joshua's behavior is supported by evidence? A. Military children often pretend to have symptoms of PTSD to get secondary gains. B. This is a common symptom of substance abuse and drug-seeking behavior. C. It is not uncommon for children of parents with PTSD to experience secondary trauma. D. Joshua's experience is indicative of impending psychosis.

C

Sam, a 50-year-old veteran with a TBI was recently diagnosed with Alzheimer's Disease. His sister asks the nurse, "How can this be an accurate diagnosis? There is no incidence of this in our family." Which of these teaching points is accurate for the nurse to share with Sam's sister? A. Alzheimer's disease doesn't tend to run in families. B. Alzheimer's disease is often misdiagnosed in patients with PTSD. C. Alzheimer's disease is more common in patients with TBI than in the general population. D. Alzheimer's disease in patients with TBI is not like traditional Alzheimer's disease.

C

Susan returned from active duty and is being treated for posttraumatic stress disorder (PTSD). She tells the nurse that she was never in a combat zone during her deployment, and her commanding officer told her that you can't have PTSD unless you were in active combat. Which of these responses by the nurse is an accurate reflection about PTSD in military personnel? A. Women may experience other anxiety disorders but rarely experience PTSD because of being in the military. B. PTSD after serving in the military is almost always related to trauma associated with active combat. C. Women in the military more often experience PTSD secondary to sexual assault. D. All of the above

C

The mental health nurse is developing a teaching plan for a community presentation on mental illness. Which should the nurse include in the teaching plan? A. Homelessness is a primary cause of mental illness. B. Access to mental health services is widely available. C. Public attitudes and stigma are barriers to treatment. D. Clients with mental illness are likely to harm others.

C

When planning care for clients diagnosed with personality disorders, which treatment outcome should the nurse anticipate? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationship D. To decrease the prevalence of neurotransmitters at receptor sites

C

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." The nurse recognizes this client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

C

Which should be the priority nursing intervention when caring for a child diagnosed with Conduct Disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.

C

A client diagnosed with NCD due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes that these symptoms indicate which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

D

A client is diagnosed with Hypoactive Sexual Desire Disorder. Which of the following are recognized as treatment options? A. Testosterone injections B. Couples therapy C. Cognitive therapy D. All of the above.

D

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate reply? A. "These clients don't know life any other way, and change is not an option until they have improved insight." B. "These clients have limited skills and few vocational abilities to be able to make it on their own." C. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

D

A nursing instructor is teaching about pharmacological treatments for ADHD. Which information about atomoxetine (Strattera) should be included in the lesson plan? A. Atomoxetine (Strattera), unlike methylphenidate (Ritalin), is a CNS depressant. B. When taking atomoxetine (Strattera), a client should eliminate all red food coloring from the diet. C. Atomoxetine (Strattera) will be a life-long intervention for clients diagnosed with this disorder. D. Atomoxetine (Strattera), unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor (SNRI).

D

A nursing instructor is teaching students about the differences between partial and inpatient hospitalization. In what way does partial hospitalization differ from traditional inpatient hospitalization? A. Partial hospitalization does not provide medication administration and monitoring. B. Partial hospitalization does not use an interdisciplinary team. C. Partial hospitalization does not offer a comprehensive treatment plan. D. Partial hospitalization does not provide supervision 24 hours a day.

D

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder? A. I was just trying to be like everyone else. B. All the skaters on the team are following an approved 1,200-calorie diet. C. When I lose skating competitions, I also lose my appetite. D. I am angry at my mother. I can get her approval only when I win competitions.

D

A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should the nurse suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman might be a victim of incest.

D

Bill is an only child whose parents are both career military personnel. He is seen by the school nurse for complaints of fever and wants to be sent home. On examination, he is afebrile. He tells the nurse he doesn't like this school anyway and the nurse notes that this is his third school transition in four years. Which of these understandings about the experience of military family members is important to providing compassionate care for this child? A. Military children are more often exposed to unusual viruses, so he should be sent for a complete evaluation and bloodwork. B. Military children are generally healthier than their nonmilitary peers, so he should be given strict consequences for pretending to be ill. C. Children of military personnel are often victims of physical abuse, so he should be asked direct questions about whether his parents have been physically aggressive with him. D. Isolation and alienation are common experiences of military family members, so it is important to assess further his adjustment in the current school setting.

D

Brian is seeking treatment for PTSD following his tour of duty in a combat zone. He reports to the assessment nurse that he has been smoking pot and drinking alcohol daily for the past 4 days because he just can't stand feeling depressed all the time. Which of these assessments is the nurse's highest priority? A. Amount of current cannabis use B. Marital status C. Neurological assessment D. Suicide risk assessment

D

Carl is treated for PTSD after returning from military combat. He sustained a mild traumatic brain injury (TBI) secondary to an explosive device blast while in combat. The nurse decides to conduct additional screening assessments based on knowledge of common comorbidities that occur with these conditions. Which of these screening assessments would be relevant? A. CAGE screen for alcohol abuse B. Beck Depression Inventory C. Mini-Mental Status Examination D. All of the above

D

Roger has been newly diagnosed with a Comorbid Psychosis. With an understanding of the neurobiology of violence, which of the following classifications of medication will the physician likely prescribe to help control aggression and violence? A. Selective serotonin reuptake inhibitors (SSRIs) B. Mood stabilizers (Tegretol, Dilantin, Depakote, lithium) C. Anti-adrenergic agents (propranolol) D. Antipsychotics (typical and atypical)

D

Sophie is 11 years old, with a diagnosis of ADHD. Her parents report and provide documentation from her teachers that Sophie is distracted easily and is unable to complete classroom activities even in the presence of minimal stimulation. A nursing diagnosis of noncompliance with task expectations has been determined, with a short-term goal that Sophie will participate in and cooperate during therapeutic activities. What nursing intervention is most appropriate? A. Establish goals that allow Sophie to complete part of the task, rewarding each step completion with a break for physical activity. B. Ask Sophie to repeat instructions to you. C. Provide assistance on a one-to-one basis, beginning with simple, concrete instructions. D. Provide an environment for task efforts that is as free of distractions as possible.

D

The nurse in the ED assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which should be the nurse's first action? A. Contact the parents. B. Administer oxygen. C. Open the crash cart. D. Administer naloxone (Narcan).

D

Which developmental characteristic should the nurse identify as typical of a client diagnosed with Severe Intellectual Disability? A. The client can perform some self-care activities independently. B. The client has advanced speech development. C. Other than possible coordination problems, the client's psychomotor skills are not affected. D. The client communicates wants and needs by "acting out" behaviors.

D

Which indicates the reason behavior modification programs are the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

D

Which medication orders should the nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

D

Which nursing diagnosis should the nurse identify as appropriate when working with Schizoid Personality Disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

D

Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a shelter for battered women

D