MENTAL HEALTH TEST 5

A mental health nurse is interviewing a flood victim whose partner was killed in the disaster. What possible patient response should the nurse anticipate in planning patient care? 1. Anticipatory grief 2. Survivor guilt 3. Unresolved grief 4. Ambiguous loss

Answer: 2 Explanation: 2. Survivor guilt occurs when one person survives and another dies and the survivor is burdened by guilt about living. In anticipatory grief, an individual expects the loss before it occurs. Unresolved grief occurs when individuals suppress or avoid grief. Ambiguous loss occurs when circumstances surrounding the loss are uncertain.

The nurse suspects that the patient who was brought to the emergency department (ED) because of what the family describes as "a sudden case of Alzheimer disease" may have general amnesia. Which characteristics make the nurse suspect general amnesia? Select all that apply. 1. The patient cannot remember any personal information. 2. The patient has been wandering away from home. 3. The patient describes a "detachment" from her mind. 4. The patient feelings of "disconnection" with her home. 5. The patient has developed an alternate personality.

Answer: 1, 2

When assessing patients with dissociative disorders, the nurse knows that which assessments are most important? 1. Pain, bowel sounds, behaviors 2. Anxiety, B12 level, heart sounds 3. LOC, patient safety, and level of anxiety 4. Facial expression, body image, pupillary reactivity

Answer: 3 Explanation: 3. When assessing patients with dissociative symptom disorders, it is important to assess patient safety, level of consciousness, and anxiety level. The other choices are more appropriate for assessing the patient with a somatic symptom or related disorder.

A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file. B. Instruct the client's partner to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

A. A power of attorney document does not address the client's care or the concerns of the caregiver. B. Clients in late-stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not an appropriate action. C. CORRECT: Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities. D. Placement of an enteral feeding tube is appropriate only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members.

A nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority? A. Administer flumazenil. B. Identify the client's level of orientation. C. Infuse IV fluids. D. Prepare the client for gastric lavage.

A. Administering flumazenil is an appropriate action. However it is not 4. the priority when taking the nursing process approach to client care. B. CORRECT: When taking the nursing process approach to client care, the initial step is assessment. Identifying the client's level of orientation is the priority action. C. Infusing IV fluids is an appropriate action. However, it is not the priority when taking the nursing process approach to client care. D. Gastric lavage is an appropriate action. However, it is not the priority when taking the nursing process approach to client care.

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all that apply.) A. An adverse effect of this medication is CNS depression. B. Administer the medication in the morning. C. Monitor for weight loss while taking this medication. D. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. E. This medication blocks the blocking the synaptic reuptake of serotonin in the brain.

A. An adverse effect of fluoxetine is CNS stimulation rather than CNS depression. B. CORRECT: Fluoxetine should be administered in the morning due to the potential for insomnia. C. CORRECT: Fluoxetine can result in weight loss. D. Fluoxetine takes 4 weeks to fully develop therapeutic effects. E. CORRECT: Fluoxetine works by blocking the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons.

A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching? A. "Behaviors associated with ADHD are present prior to age 3." B. "This disorder is characterized by argumentativeness." C."Below-average intellectual functioning is associated with ADHD." D."Because of this disorder, your child is at an increased risk for injury."

A. Behaviors associated with ADHD are present before the age of 12. B. Argumentativeness is associated with oppositional defiant disorder rather than ADHD. C. Below-average intellectual functioning is associated with intellectual developmental disorder rather than ADHD. D. CORRECT: Inattentive or impulsive behavior increases the risk for injury in a child who has ADHD.

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding? (Select all that apply.) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

A. Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome. B. CORRECT: Respiratory distress is an expected finding of shaken baby syndrome. C. CORRECT: Retinal hemorrhage is an expected finding of shaken baby syndrome. D. CORRECT: An altered level of consciousness is an expected finding of shaken baby syndrome due to intracranial trauma or hemorrhage. E. CORRECT: An increase in head circumference is an expected finding of shaken baby syndrome.

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide? A. Three to six weeks of treatment is required to achieve therapeutic benefit. B. Combining alcohol with diazepam will produce a paradoxical response. C. Diazepam has a lower risk for dependence than other antianxiety medications. D. Report confusion as a potential indication of toxicity.

A. Buspirone, rather than diazepam, requires 3 to 3. 6 weeks to achieve therapeutic benefit. B. Combining alcohol with diazepam can produce CNS and respiratory depression rather than a paradoxical response. C. Diazepam is preferably used for short-term treatment because of the increased risk of dependence. D. CORRECT: Confusion is a potential indication of diazepam toxicity that the client should report to the provider.

A nurse is obtaining a health history from the parents of a 12-year-old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Bullyingofothers B. Threats of suicide C. Law-breaking activities D. Narcissistic behavior E. Flat affect

A. CORRECT: Bullying behavior is an expected finding of conduct disorder. B. CORRECT: Suicidal ideation is an expected finding of conduct disorder. C. CORRECT: Law- and/or rule-breaking behavior is an expected finding of conduct disorder. D. Low self-esteem, rather than narcissism, is an expected finding of conduct disorder. E. Irritability and temper outbursts, rather than a flat affect, are expected findings of conduct disorder.

A nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply.) A. Concurrent administration of buspirone B. Administration of a different SSRI C. Use of a mouth guard D. Changing to a different class of antianxiety medication E. Increasing the dose of paroxetine

A. CORRECT: Concurrent administration of a low-dose of buspirone is an effective measure to manage the adverse effect of paroxetine. B. Other SSRIs will also have bruxism as an adverse effect therefore this is not an effective measure. C. CORRECT: Using a mouth guard during sleep can decrease the risk for oral damage resulting from bruxism. D. CORRECT: Changing to a different class of antianxiety medication that does not have the adverse effect of bruxism is an effective measure. E. Increasing the dose of paroxetine can cause the adverse effect of bruxism to worsen therefore this is not an effective measure.

A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the client's mattress on the floor. E. Installlightfixturesabovestairs.

A. CORRECT: Door locks that are difficult to open are appropriate to reduce the risk of the client wandering outside without supervision. B. Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered. C. Cleaning supplies should be placed in locked cupboards. Marking the supplies with colored tape does not prevent the client's access to hazardous materials. D. CORRECT: Placing the client's mattress on the floor reduces the risk for falls out of bed. E. CORRECT: Stairs should have adequate lighting to reduce the risk for falls.

A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber. B. Check temperature daily. C. Take medication first thing in the morning before eating. D. Add extra calories to the diet as between-meal snacks.

A. CORRECT: Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use. B. Checking the client's temperature daily is not necessary while taking a TCA. C. Taking the medication at bedtime rather than in the morning is appropriate to prevent daytime sleepiness. D. Following a well-balanced diet plan rather than adding extra calories as snacks will help prevent weight gain, a common adverse effect of TCAs.

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply.) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who completed suicide C. Educating high school teens about suicide prevention D. Initiating one-on-one observation for a client who has current suicidal ideation E. Teaching middle-school educators about warning indicators of suicide

A. CORRECT: Primary interventions include suicide prevention through the use of screenings to identify individuals at risk. Conducting a suicide risk screening on all new clients is an example of a primary intervention. B. Creating a support group for family members of clients who completed suicide is an example of a tertiary intervention. C. CORRECT: Primary interventions include suicide prevention through the use community education. Educating high school teens about suicide prevention is an example of a primary intervention. D. Initiating one-on-one observation for a client who has current suicidal ideation is an example of a secondary intervention. E. CORRECT: Primary interventions include suicide prevention through the use community education. Educating middle-school teachers to recognize the warning indicators of suicide is an example of a primary intervention.

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply.) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C."I can expect to experience changes in sleep." D."It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self-esteem."

A. CORRECT: Resentment is an emotion that can be associated with normal grief. B. CORRECT: Withdrawal is an emotion that can be seen with normal grief. C. CORRECT: Somatic manifestations such as changes in sleep patterns can be associated with normal grief. D. Suicidal ideations are associated with maladaptive grieving. The client who is experiencing a distorted or exaggerated grief response can direct anger towards himself. The nurse should assess and monitor the client for thoughts of suicide or self-injury. E. A client who is experiencing a maladaptive grief response commonly experiences a loss of self-esteem and a sense of worthlessness. These findings are not associated with normal grief.

A nurse is teaching the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Seizures B. Agitation C. Photophobia D. Dry mouth E. Irregular pulse

A. CORRECT: Seizures are an indication of TCA toxicity. B. CORRECT: Agitation is an indication of TCA toxicity. C. Photophobia is an anticholinergic effect rather than an indication of TCA toxicity. D. Dry mouth is an anticholinergic effect rather than an indication of TCA toxicity. E. CORRECT: Irregular pulse can indicate a dysrhythmia which is an indication of TCA toxicity.

A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction? (Select all that apply.) A. Sudden development of phobias B. Development of substance use disorder C. Increased level of anxiety during interview D. Reactivation of a prior physical disorder E. Unwillingness to discuss the sexual assault

A. CORRECT: Sudden onset of phobic reactions is a characteristic of a silent rape reaction. B. Development of substance use disorder is a characteristic of a compound rape reaction. C. CORRECT: Increased anxiety during interview is a characteristic of a silent rape reaction. D. Reactivation of a prior physical disorder is a characteristic of a compound rape reaction. E. CORRECT: No verbalization of the sexual assault is a characteristic of a silent rape reaction.

A nurse is working with a client who has recently lost his mother. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (Select all that apply.) A. Interpersonal relationships B. Culture C. Birth order D. Religious beliefs E. Prior experience with loss

A. CORRECT: The client's interpersonal relationships are factors which influence the client's reaction to grief and ability to cope. B. CORRECT: The client's culture is a factor that influences the client's reaction to grief and ability to cope. C. Birth order is not a factor that influences grief and ability to cope. D. CORRECT: The client's religious beliefs are factors that influences the client's reaction to grief and ability to cope. E. CORRECT: The client's prior experience with loss is a factor that influences the client's reaction to grief and ability to cope.

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of women's shelters. B. Encourage the client to participate in a support group for survivors of abuse. C. Implement case management to coordinate community and social services. D. Educate the client about the use of stress management techniques.

A. CORRECT: The greatest risk to this client is injury from intimate partner abuse; therefore, the priority action the nurse should take is to assist the client with the development of a safety plan that includes the identification of safe places to live. B. The nurse should encourage participation in a support group. However, this does not address the greatest risk to the client and is therefore not the priority nursing action. C. The nurse should implement case management. However, this does not address the greatest risk to the client and is therefore not the priority nursing action. D. The nurse should educate the client about the use of stress management techniques. However, this does not address the greatest risk to the client and is therefore not the priority nursing action.

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C."I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D."I should use narrative documentation when documenting subjective data."

A. CORRECT: The nurse should administer prophylactic treatment for infections such as chlamydia according to the Centers for Disease Control and Prevention. B. The nurse must obtain informed consent to collect data that can be used as legal evidence. C. Manifestations of rape-trauma syndrome are similar to posttraumatic stress disorder. D. The nurse should document subjective data, using the client's verbatim statements.

A nurse is caring for a client who lost his mother to cancer last month. The client states, "I'd still have my mother if the doctor would have diagnosed her sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C."I understand just how you feel. I felt the same when my mother died." D."Do other members of your family also feel this way?"

A. CORRECT: This is a therapeutic response for the nurse to make. This response acknowledges the client's emotion and provides education on the normal grief response. B. This response offers advice, which is a nontherapeutic communication technique. C. This response minimizes the client's feelings and takes the focus away from the client ,which are nontherapeutic communication techniques. D. This response takes the focus away from the client, which is a nontherapeutic communication technique.

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C."You will not get your way by screaming." D."What was going through your mind when you started screaming?

A. CORRECT: This is an appropriate therapeutic response. Setting limits and the use of physical activity, such as walking, to deescalate anger is an appropriate intervention. B. "Why" questions imply criticism and will often cause the client to become defensive. C. This is a closed-ended, nontherapeutic statement. D. The client is not ready to discuss this issue.

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (Select all that apply.) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C."I wish my life was over." D."I don't feel like I can ever be happy again." E. "If I kill myself then my problems will go away."

A. CORRECT: This statement is an overt comment about suicide in which the client directly talks about his perception of an outcome of his death. The nurse should assess the client further for a suicide plan. B. This statement is a covert comment in which the client identifies a problem but does not directly talk about suicide. The nurse should assess the client further for suicidal ideation. C. CORRECT: This statement is an overt comment about suicide in which the client directly talks about his wish to no longer be alive. The nurse should assess the client further for a suicide plan. D. This statement is a covert comment in which the client identifies a problem but does not directly talk about suicide. The nurse should assess the client further for suicidal ideation. E. CORRECT: This statement is an overt comment about suicide in which the client directly talks about his perception of an outcome of his completed suicide. The nurse should assess the client further for a suicide plan.

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 3 are at greater risk for abuse" B. "Substance use disorder does not increase the risk for violence." C."Entering an intimate relationship increases the risk for violence." D."Pregnancy increases the risk for violence toward the intimate partner."

A. Children younger than 3 years of age are at an increased risk for abuse. B. Substance use disorder increases the risk for violence. C. Vulnerable persons are an increased risk for violence when they try to leave the relationship. D. CORRECT: Pregnancy tends to increase the likelihood of violence toward the intimate partner.

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donepezil." C."You will be screened for underlying kidney disease prior to starting donepezil." D."You should stop taking donepezil if you experience nausea or diarrhea."

A. Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding. B. CORRECT: Donepezil slows the cognitive deterioration of Alzheimer's disease. C. Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease, prior to treatment. D. Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction. However, the client should not abruptly stop the medication without consulting a provider.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. Assign the client to a private room. B. Document the client's behavior every hour. C. Allow the client to keep perfume in her room. D. Ensure that the client swallows medication.

A. Clients who are suicidal should not be assigned a private room. B. Client's behavior should be documented every 15 min or according to facility policy. C. Remove perfume from the client's room. D. CORRECT: Ensure that the client swallows medication to prevent hoarding of medication for an attempted overdose.

The nurse caring for a patient admitted with somatic symptom disorder questions the health care provider about which orders? Select all that apply. 1. Morphine 4 mg PO prn pain 2. Alprazolam 2 mg PO prn anxiety 3. Teach patient breathing techniques 4. Psychotherapy with family involvement 5. Walk 15-30 minutes per day in neighborhood

Answer: 1, 2 Explanation: 1. Medication is not advised for individuals with somatic symptom and related disorders. The most effective ways of treating this disorder are cognitive-behavioral therapy and complementary/alternative therapies. 2. Medication is not advised for individuals with somatic symptom and related disorders. The most effective ways of treating this disorder are cognitive-behavioral therapy and complementary/alternative therapies.

A charge nurse is reviewing Kübler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply.) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

A. Disequilibrium is the second stage of Bowlby's four stages of grief. B. CORRECT: The denial stage is when the client has difficulty believing a terminal diagnosis or loss. This is one of Kübler-Ross Five Stages of Grief. C. CORRECT: The bargaining stage is when the client negotiates for more time or a cure. This is one of Kübler-Ross Five Stages of Grief. D. CORRECT: The anger stage is when the client directs anger toward self, others, or objects. This is one of Kübler-Ross Five Stages of Grief. E. CORRECT: The depression stage is when the client mourns and directly confronts feelings related to the loss. This is one of Kübler-Ross five stages of grief.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express her feelings. B. Maintain eye contact with the client. C. Move the client away from others. D. Tell the client that the behavior is not acceptable.

A. Encouraging the client to express her feelings is appropriate. However, it is not the priority action. B. Maintaining eye contact with the client is appropriate. However, it is not the priority action. C. CORRECT: The client's behavior indicates that he is at greatest risk for harming others. The priority action for the nurse is to move the client away from others. D. It is appropriate to tell the client that the behavior is not acceptable. However, it is not the priority action.

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

A. Fever, rather than hypothermia, is an indication of serotonin syndrome. B. CORRECT: Hallucinations are an indication of serotonin syndrome. C. Muscle tremors, rather than flaccidity, are an indication of serotonin syndrome. D. CORRECT: Diaphoresis is an indication of serotonin syndrome. E. CORRECT: Agitation is an indication of serotonin syndrome.

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply.) A. Genitourinary soreness B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

A. Genitourinary soreness indicates a somatic reaction. B. Difficulties with low self-esteem are an indication of a sustained and maladaptive emotional response beyond the initial reaction. C. Sleep disturbances indicates a somatic reaction. D. CORRECT: Emotional outbursts indicate an expressed initial reaction of rape-trauma syndrome. E. CORRECT: Difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome.

A nurse is assessing a 4-year-old child forindicationsofautismspectrum disorder. For which of the following manifestations should the nurse assess? A. Impulsive behavior B. Repetitive counting C. Destructiveness D. Somatic problems

A. Impulsive behavior is an indication of ADHD rather than autism spectrum disorder. B. CORRECT: Repetitive actions and strict routines are an indication of autism spectrum disorder. C. Destructiveness is an indication of conduct disorder rather than autism spectrum disorder. D. Somatic problems are an indication of posttraumatic stress disorder rather than autism spectrum disorder.

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all that apply.) A. Somnolence B. Yellowing skin C. Increased appetite D. Fever E. Malaise

A. Insomnia, rather than somnolence, is an adverse effect that the client should report to the provider. B. CORRECT: Yellowing skin is a potential indication of hepatotoxicity that the client should report to the provider. C. Decreased appetite with resulting weight loss, rather than increased appetite, is a potential adverse effect that the client should report to the provider. D. CORRECT: Fever is a potential indication of hepatotoxicity that the client should report to the provider. E. CORRECT: Malaise is a potential indication of hepatotoxicity that the client should report to the provider.

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention-seeking behavior. B. Interventions are ineffective for clients who really want to commit suicide. C. Using the term suicide increases the client's risk for a suicide attempt. D. A no-suicide contract decreases the client's risk for suicide.

A. It is a myth that a threat of suicide or suicide attempt is attention-seeking behavior. B. It is a myth that interventions are ineffective for clients who really want to commit suicide. Suicide precautions are shown to be effective in reducing the risk of a completed suicide. C. It is a myth that using the term suicide increases the client's risk for a suicide attempt. The nurse should discuss suicide openly with the client. D. CORRECT: The use of a no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies.

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.) A. Lethargy B. Defensive responses to questions C. Disorientation D. Facial grimacing E. Agitation

A. Lethargy is more likely to be observed in a client who has depression. B. CORRECT: Defensive responses to questions are an assessment finding that can indicate that a client is in the preassaultive stage of violence. C. Disorientation is more likely to be assessed in a client who has a cognitive disorder. D. CORRECT: Facial grimacing is an assessment finding that can indicate that a client is in the preassaultive stage of violence. E. CORRECT: Agitation is an assessment finding that can indicate that a client is in the preassaultive stage of violence.

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. When conducting a head-to-toe assessment, which of the following findings should alert the nurse to possible abuse? (Select all that apply.) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

A. Minor injuries, such as abrasions, on the arms and legs are common in this age group. B. CORRECT: Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse. C. Mismatched clothing is consistent with the child's developmental age. D. Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse. E. CORRECT: Areas of ecchymosis on the torso, back, or buttocks should alert the nurse to possible abuse.

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (Select all that apply.) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

A. Mood stabilizers, such as lithium carbonate, are prescribed for bipolar disorder and are not indicated in a short-term crisis situation. B. CORRECT: SSRI antidepressants, such as paroxetine, may be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis. C. Antipsychotic medications, such as risperidone, may be prescribed for disturbed thought processes, usually when accompanied by other psychotic symptoms (hallucinations, delusions, blunt affect). Antipsychotics are not indicated in a short-term crisis situation. D. Antipsychotic medications, such as haloperidol, may be prescribed for disturbed thought processes, usually when accompanied by other psychotic symptoms (hallucinations, delusions, blunt affect). Antipsychotics are not indicated in a short-term crisis situation. E. CORRECT: Benzodiazepines, such as lorazepam, may be prescribed to decrease the anxiety of a client who is experiencing a crisis.

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C."Young adults are the typical victims of sexual assault." D."The majority of rapists are unknown to the victims."

A. Rape is a crime of violence, aggression, anger, and power. B. CORRECT: Alcohol and other substances are often associated with date or acquaintance rape. C. Individuals of all ages are affected by sexual assault and can be male or female. D. The majority of perpetrators are known to the vulnerable persons.

A nurse is conducting chart reviews of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

A. Rape is an example of an adventitious crisis. It is not a part of everyday life. B. CORRECT: Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span. C. Severe physical illness is an example of a situational crisis. D. Loss of a job is an example of a situational crisis.

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing an older adult to fall is an example of physical violence. C. Striking an intimate partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse.

A. Refusing to pay bills for a dependent is economic maltreatment, rather than neglect. B. CORRECT: Physical violence occurs when physical pain or harm is directed toward another individual. C. Striking an intimate partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent. D. Failure to provide a stimulating environment for normal development is neglect, rather than emotional abuse.

A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following manifestations should the nurse expect? (Select all that apply.) A.Fear of being alone B.Substance use C. Weight gain D. Irritability E.Aggressiveness

A. Solitary play or work, rather than the fear of being alone, is an expected finding associated with depression. B. CORRECT: Substance use is an expected finding associated with depression. C. Loss of appetite and weight loss, not weight gain, are expected findings associated with depression. D. CORRECT: Irritability is an expected finding associated with depression. E. CORRECT: Aggressiveness is an expected finding associated with depression.

A nurse is caring for a client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet while taking this medication." C."I will need to discontinue this medication slowly." D."I will be at risk for weight loss with long-term use of this medication."

A. The client should take fluoxetine in the morning to minimize sleep disturbances. B. The client is at risk for hyponatremia while taking fluoxetine. C. CORRECT: When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal syndrome. D. The client is at risk for weight gain, rather than loss, with long-term use of fluoxetine.

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

A. The client who has delirium can experience memory loss with sudden rather than gradual onset. B. CORRECT: The client who has delirium can experience rapid personality changes. C. CORRECT: The client who has delirium can have perceptual disturbances, such as hallucinations and illusions. D. The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate. E. CORRECT: The client who has delirium commonly exhibits restlessness and agitation.

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C."Why would you want to leave? Aren't you happy with your care?" D."I am your nurse. Let's walk together to your room."

A. The nurse should avoid statements that can be interpreted as argumentative or demeaning. B. The nurse should use positive, rather than negative, statements. C. Using a "why" question can promote a defensive reaction and does not reinforce reality. D. CORRECT: It is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling. B. Request that other staff members remain close by. C. Move as close to the client as possible. D. Walk away from the client.

A. The nurse should not make demands of the client by insisting that he stop yelling. B. CORRECT: The nurse should request that other staff members remain close by to assist if necessary. C. Clients who are angry need a large personal space. D. The nurse should never walk away from a client who is angry. It is the nurse's responsibility to intervene as appropriate.

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.) A. Allow the child to choose consequences for negative behavior. B. Use role-playing to act out unacceptable behavior. C. Develop a reward system for acceptable behavior. D. Encourage the child to participate in school sports. E. Be consistent when addressing unacceptable behavior.

A. The parents should set clear limits on unacceptable behavior. B. The parents should focus on acceptable behavior and demonstrate this through modeling. C. CORRECT: The parents should have a method to reward the child for acceptable behavior. D. CORRECT: The parents should encourage physical activity through which the child can use energy and obtain success. E. CORRECT: The parents should set clear limits on unacceptable behavior and should be consistent.

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. Apply the patch once daily at bedtime. B. Place the patch carefully in a trash can after removal. C. Apply the transdermal patch to the anterior waist area. D. Remove the patch each day after 9 hr.

A. The transdermal patch is applied once daily in the morning. B. For safety when discarding the transdermal preparation, the client should fold the patch and flush it down the toilet to prevent others from using it. C. The transdermal patch should be applied to a clean, dry area on the hip, and the waist area should be avoided. D. CORRECT: The transdermal patch is applied once daily in the morning and is removed after 9 hr.

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

A. This is an appropriate assessment for the nurse to include. However, it is not the priority. B. CORRECT: The greatest risk to the client is self-harm as a result of carrying out a suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is. C. This is an appropriate assessment for the nurse to include. However, it is not the priority. D. This is an appropriate assessment for the nurse to include. However, it is not the priority.

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C."You believe this wouldn't have happened if you hadn't been out alone?" D."Why do feel that you should not have been alone on the street at night?"

A. This response offers the nurse's opinion, which is a nontherapeutic communication technique. B. This responses indicates disapproval, which is a nontherapeutic communication technique. C. CORRECT: This response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings. D. This responses asks a "why" question, which is a nontherapeutic communication technique.

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry." B. "I feel angry when you leave me." C."It makes me angry when you interrupt me." D."You'd better listen to me."

A. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. B. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. C. This statement does not imply a threat, nor does it indicate a lack of respect for another individual. D. CORRECT: This statement implies a threat and a lack of respect for another individual.

A 79-year-old patient lost his spouse six months ago. What are some risk factors the nurse should consider in assessing this patient? Select all that apply. 1. Impaired health 2. Accident frequency 3. Increased alcohol use 4. Involvement in new relationships 5. Increased involvement with children

Answer: 1, 2, 3

The school nurse is meeting with a child and his parents. The child was recently diagnosed with autism spectrum disorder (ASD). What is an appropriate goal for this first meeting? 1. Provide information on ASD. 2. Improve the child's school behavior. 3. Determine the causes of the child's ASD. 4. Determine an appropriate medication regimen for the child.

Answer: 1 Explanation: 1. A first session should include education about symptoms, the impact on functioning, and possible therapies. The first session should not be focused on predetermined behavioral objectives; over the long term, the nurse should focus on how patient needs can be articulated and addressed as specific, realistic, and measurable goals for the patient's care and include the patient in developing them. Theories on the causes of ASD examine various possible etiologies but definitive causes are still not determined. A psychopharmacologist or child psychiatrist should be considered to assess the appropriate medication regimen.

A nurse is designing a hospital program for parents who have lost a child. What intervention might be most useful to include? 1. Support group 2. Educational brochure 3. Informational workshop 4. Medication evaluation

Answer: 1 Explanation: 1. A support group can provide parents with the opportunity to connect with others who have experienced a similar loss. Although a brochure or a workshop might provide information that parents wants to know, a brochure does not provide emotional solace during the grieving process. A medication evaluation may not be indicated for every grieving parent.

The nurse is caring for a patient who is a victim of interpersonal violence (IPV). What is the nurse's first priority? 1. Assist the patient to devise a safety or escape plan. 2. Encourage the patient to take charge of the situation. 3. Make it clear to the patient that the partner needs to see a therapist. 4. Offer to contact outpatient services if the patient promises not to return home after discharge.

Answer: 1 Explanation: 1. A victim of intimate partner violence should have a safety plan. This is the highest priority because the patient's physical and/or mental health is in danger. The nurse should not assume that the patient will be able to control the partner, and suggesting that the patient tell the abusive partner to see a therapist could escalate the abuse. Encouraging a patient to take charge is a very general suggestion. The patient needs specific tools to develop a safety plan. It may not be safe or feasible for the patient to leave home right away, and resources should not be withheld if a patient is unable to promise to leave home.

The nurse is caring for a group of patients who are all active duty military. Which patient statement would the nurse identify as increasing the patient's risk for suicide? 1. "I drink alcohol when I need to relax." 2. "My children stress me out sometimes." 3. "I graduated college, but my grades were not great." 4. "I have never been deployed to a war zone."

Answer: 1 Explanation: 1. Active duty military personnel are at increased risk for suicide. However, additional factors may further increase their risk. These include substance use, history of deployment to an active war zone, and not having attended or graduated from college. Those who have children are more likely to have protective measures against suicide, due to the fact that they are responsible for caring for another person's basic needs.

The nurse is conducting a health history on a newly admitted patient. The patient's wife tells the nurse, "Ever since my husband's head injury, he is easily agitated, cannot focus, and is impulsive." What is the best response from the nurse? 1. "Your husband's injuries may have damaged the prefrontal cortex of the brain, causing these symptoms." 2. "Your husband's injuries may have damaged the occipital lobe of the brain, causing these symptoms." 3. "Your husband's injuries may have damaged the parietal lobe of the brain, causing these symptoms." 4. "Your husband's injuries may have damaged the cerebellum of the brain, causing these symptoms."

Answer: 1 Explanation: 1. Damage to the prefrontal cortex of the brain may manifest as agitation, inability to focus, and impulsivity. Damage to the occipital lobe would likely manifest in alterations in visual perception. Damage to the parietal lobe would exhibit as alterations in visual-spatial coordination. Damage to the cerebellum would manifest in poor balance and decreased fine motor control.

The nurse is caring for a patient with Alzheimer disease and anticipates an order for which medication that may help delay the rate of cognitive decline? 1. Donepezil (Aricept) 2. Quetiapine (Seroquel) 3. Valproic acid (Depakote) 4. Escitalopram (Lexapro)

Answer: 1 Explanation: 1. Donepezil (Aricept) is used to slow the rate of cognitive decline in patients with Alzheimer disease. Quetiapine (Seroquel) is used to reduce or eliminate delusions and hallucinations in patients diagnosed with vascular dementia with psychosis. Escitalopram (Lexapro) is used to treat depressive symptoms in patients with Lewy body dementia. Valproic acid (Depakote) is used to reduce mood swings seen in Pick disease and other mood disorders.

A patient who lost a grandchild over a year ago recently stopped taking her anti-depressant medication. When assessing the patient, which finding would suggest a relapse of the patient's depression? 1. Changes in the patient's sleep patterns 2. Increased patient talk about her grandchild 3. Continuing patient participation in a grief support group 4. Patient involvement in creating a memorial scholarship fund.

Answer: 1 Explanation: 1. Early signs of relapse of depression may include sleep difficulties that recur after a period of improvement. Talking about a loved one can be an effective strategy for coping with loss. Participating in creating an appropriate memorial can also support healing. Ongoing participation in treatment is an indication of effective involvement, not of relapse.

) The nurse is working in the emergency department (ED) of a local hospital. Which response by a patient or family member would alert the nurse to the greatest risk for displaying aggression? 1. "My brother is in a lot of pain and can't get comfortable." 2. "I am worried about my husband's condition after his heart attack." 3. "I am nervous about the upcoming surgery to repair my broken arm." 4. "My mother is very short of breath but the medication seems to be helping."

Answer: 1 Explanation: 1. Emergency departments (ED) are susceptible to violence by patients, visitors, and family members. Factors that increase the risk for violence include treatment of conditions such as anxiety, long wait times, and painful procedures. The individual whose brother in a lot of pain is at greatest risk for displaying aggression. The spouse who is concerned about the patient's condition is not at an increased risk for aggression. The patient who is nervous or apprehensive about an upcoming surgical procedure is not at an increased risk for aggression.

The nurse is caring for patients in the aftermath of a tornado that has damaged several homes and the local elementary school. What will the nurse address during patient education sessions? 1. Basic coping skills 2. Long-term interventions 3. Patient-nurse collaboration 4. Therapeutic communication

Answer: 1 Explanation: 1. Following a community-wide crisis, the nurse will focus patient education on basic coping skills. Rather than providing education on long-term interventions, the nurse should focus education on short-term interventions. Taking a direct and instructional approach to crisis education is more important than patient-nurse collaboration. The nurse will not provide patient education on therapeutic communication during crisis; rather, the nurse will use therapeutic communication when providing patient education.

A nurse is working with a family that demonstrates a high level of conflict. Which intervention would be most appropriate? 1. Help them to learn more effective communication skills. 2. Help them obtain medication to decrease their intensity levels. 3. Help them to identify the family member who is causing the conflict. 4. Help them decide which family member should have the most power in decision making.

Answer: 1 Explanation: 1. Helping the family members to better advocate and communicate within the family would help to decrease the high emotion at home, improve social support, and provide a backdrop for more effective problem solving in the home. Medication is indicated for serious mental health disorders, not for resolving conflicts. Identifying a family member as causing conflict (identified patient role) is an indication of family dysfunction, not an intervention to resolve it. Collaborative, rather than authoritative, decision making helps resolve conflicts.

A 42-year-old patient presents to the health care provider's office complaining of difficulty "remembering things." The patient's spouse adds that the patient has been making "a lot of funny faces and hasn't been himself lately." The nurse anticipates the need to evaluate the patient for which disorder? 1. Huntington disease 2. Parkinson disease 3. Traumatic brain injury 4. Human Immunodeficiency Virus

Answer: 1 Explanation: 1. Huntington disease, Parkinson disease, traumatic brain injury, and HIV can all result in memory loss and dementia. However, symptoms of Huntington disease include choreic movements including facial contortions, earlier onset, and changes in personality.

The nurse is caring for a patient who has been diagnosed with a dissociative disorder after being missing for two weeks and returning home, not knowing any time had passed. The nurse recognizes the patient is experiencing which condition associated with dissociative disorders? 1. Fugue 2. Amnesia 3. Alexithymia 4. Derealization

Answer: 1 Explanation: 1. Individuals with dissociative fugue wander, usually far from home and for days, perhaps even weeks or months, at a time. During this period, patients completely forget their past life and associations, but unlike people with amnesia, they are unaware of having forgotten anything. Individuals do not recall the fugue period when they return to consciousness. Alexithymia is the inability to label feelings with words. Derealization is the experience of unreality or detachment from the individual's surroundings.

The nurse is caring for a patient with moderate Alzheimer disease (AD). The health care provider has ordered memantine (Namenda) for the collaborative treatment of the patient's disease. What is the nurse's best understanding of this medication's action? 1. Protects cells against excess glutamate by partially blocking NMDA c-receptors. 2. Slows the degradation of acetylcholine, thereby increasing concentration of the neurotransmitters in the cerebral cortex. 3. Protects cells against excess NMDA by partially blocking glutamate c-receptors. 4. Slows the degradation of dopamine, thereby increasing concentration of the neurotransmitters in the cerebral cortex.

Answer: 1 Explanation: 1. Memantine (Namenda) is a NMDA receptor antagonist. This medication may protect cells against excess glutamate by partially blocking NMDA c-receptors. Cholinesterase inhibitors (ChEIs) are also used in the treatment of AD. These medications slow the degradation of acetylcholine, thereby increasing concentration of the neurotransmitters in the cerebral cortex.

What almost universal response to loss should a mental health nurse understand has many cultural determinants? 1. Anger 2. Crying 3. Depression 4. Distancing

Answer: 2 Explanation: 2. Although crying is an almost universal response to loss, cultural determinants affect its acceptability for different genders and ages, and the intensity of allowable expression. Depression is a mental health issue, not a universal response to loss. Anger or distancing may be responses to loss, but they are not universal.

A nurse is considering reporting suspected abuse by a step-father, but she is worried that she might jeopardize a developing relationship with the child's mother. What legal ramifications should she consider? 1. If she does not report her suspicions, she could lose her license. 2. If she makes a report, the step-father could sue her for false arrest. 3. If she makes the report, the mother could accuse her of alienation of affection. 4. If she does not make a report, her agency could be liable for any medical expenses.

Answer: 1 Explanation: 1. Nurses who have any evidence of abuse of a child are mandated by law to contact their state's department of child protective services to report concerns. Any nurse who fails to follow mandatory reporting laws can lose his or her license. Mandated reporters are protected from criminal or civil liability if they report in good faith. Parents are responsible for the child's medical costs.

The nursing staff working on the dementia unit of a long-term care facility are informed that the entire unit will be redecorated in the next two weeks. Nursing staff tell the nurse manager that this will be a problem for the patients. What particular patient need is addressed by the staff nurse's concern? 1. A stable environment 2. Patient comfort 3. Scheduling of admissions 4. Patient safety

Answer: 1 Explanation: 1. Patients with a diagnosis of dementia need a stable environment to promote optimal orientation. Patient safety, scheduling of admissions, and patient comfort may not be impacted by the redecoration efforts.

Which nursing intervention helps promote stress reduction and healthy coping in a patient diagnosed with a dissociative disorder? 1. Perform safety checks at each health care interaction. 2. Discuss activities that patients can do that eliminate the need for safety provisions. 3. Review the patient's daily personal journal to assess appetite. 4. Teach nonpharmacologic strategies for reducing pain.

Answer: 1 Explanation: 1. Performing safety checks at each health care interaction helps ensure patient safety and provides an opportunity to discuss triggers and promote healthy coping mechanisms. Discussing activities to reduce the need for safety provisions, teaching nonpharmacologic methods of reducing pain, and reviewing the patient's daily journal to assess appetite are appropriate interventions for somatic symptom disorders.

The nurse at a community health clinic is conducting a mental health assessment on a patient with a history of depression. Which environmental factor does the nurse recognize as a risk factor for suicide? 1. Isolation from others 2. Chronic illness 3. Apprehensive anxiety 4. Working two jobs

Answer: 1 Explanation: 1. Sociological or environmental influences that increase risk for suicide include isolation from others, military status, and incarceration. Working two jobs is not a risk factor for suicide. Chronic illness is a biological risk factor. Apprehensive anxiety is a psychological risk factor.

A nurse meets with a patient whose mother died recently. The patient is distressed because her brother returned to work immediately after their mother's funeral. Which is the best response by the nurse? 1. "Every person grieves in their own way." 2. "I guess your brother is just not an emotional guy." 3. "Yes, that is a problem. I think you should suggest that he see a therapist." 4. "There is an association between a lack of expression of grief and negative psychological outcomes."

Answer: 1 Explanation: 1. Sometimes conflict arises when two members of a family grieve differently and do not understand each other. There is no right or wrong grief response, and there is a lack of research evidence to show an association between lack of expression and negative psychiatric outcomes. Another misunderstanding is that emotions must be expressed them to be real and for healing to take place.

A community health nurse is providing education to a group of mental health employees regarding the influence of the economy on the suicide rate within the community. What statement by the mental health employee indicates the need for further teaching? 1. "Suicide rates increase during times of war." 2. "Suicide rates decrease during times of war." 3. "Suicide rates increase during times of economic distress." 4. "Suicide rates decrease during times of economic growth."

Answer: 1 Explanation: 1. Statistics are useful to understand trends in order to determine what population of individuals may be at risk for completion of suicide. Economic factors contribute to the suicide rate. Suicide rates decrease, not increase, during times of war. Suicide rates also increase during times of economic distress and decrease during times of economic growth.

The nurse is assessing four patients for a risk for suicide. According to the Level of Suicidal Severity Index, which patient statement indicates the greatest risk for suicide? 1. "I have no reason to live anymore, and suicide is my only option." 2. "I think committing suicide will help to solve all the problems I have." 3. "I plan to commit suicide by overdosing on prescription pain medication." 4. "I sometimes think about how suicide might solve my problems, but I would never do it."

Answer: 1 Explanation: 1. The Level of Suicidal Severity Index is a tool used by nurses and clinicians in the comprehensive assessment of a patient's risk for suicide. This index categories the patient's thoughts of suicide into five various stages of severity. The patient who can no longer identify any protective measures or a reason for living is in Stage V, and is at greatest risk for suicide. The patient who states, "I have no reason to live anymore and suicide is my only option" is best demonstrating Stage V. The patient in Stage III is beginning to consider suicide as an option for problem solving. The patient who has a plan for suicide and method to carry out the strategy is in Stage IV. The patient who begins to have fleeting thoughts of suicide, followed by thoughts that dismiss suicide is in Stage II.

A nurse is caring for a patient who has been diagnosed with dementia due to Parkinson disease. The patient has never heard of Parkinson disease and asks what causes it. What will the nurse explain is the etiology of this disorder? 1. Death of neurons 2. Presence of Lewy bodies 3. Inheritance of a dominant gene 4. Presence of an infectious process

Answer: 1 Explanation: 1. The etiology of dementia related to Parkinson disease is due to death of neurons, including those that produce dopamine, the chemical responsible for movement and coordination. The presence of Lewy bodies is the etiology for Lewy body dementia. The inheritance of a dominant gene is the etiology for dementia related to Huntington disease. The presence of an infectious process is the etiology for dementia due to prion disease.

The nurse is caring for a patient who is experiencing a crisis. What is the priority during the patient's initial crisis assessment? 1. Ensuring safety 2. Classifying the type of trauma 3. Identifying treatment and referral needs 4. Assessing the risks associated with the crisis

Answer: 1 Explanation: 1. The priority during an initial crisis assessment is to determine the safety of the individual. While the other answer choices are components of the initial crisis assessment, ensuring safety is the priority.

When planning care for a client with somatic symptom disorder the nurse knows that which activity is the most important? 1. Determine patient needs in each of the five domains. 2. Determine patient willingness to try new interventions. 3. Review patient daily journal to obtain a realistic view of the patient's activities. 4. Encourage interactions with family and friends to keep the patient's mind off of somatic issues.

Answer: 1 Explanation: 1. When planning nursing care, determining the patient's needs in each of the five domains is important to help reassure the patient, provide periodic assessment, and promote therapeutic relationships. This approach also helps to involve the patient in the planning process. The other answer choices occur during implementation of the plan of care.

The nursing staff cared for a patient who was aggressive and violent toward one of the nurses. What is the nurse manager's best immediate response? 1. Schedule a debriefing for all staff involved. 2. Schedule a staff meeting for all staff involved. 3. Schedule an educational session for all staff involved. 4. Schedule a medical record review with all staff involved.

Answer: 1 Explanation: 1. Work settings should address the need for staff to debrief after difficult interactions and interventions. Staff meetings and educational sessions do not necessarily address the need to debrief. A medical record review may be appropriate for all the staff after an encounter with a patient who is aggressive and angry; however, this is not the best immediate response from the nurse manager.

The nurse is taking care of patient admitted with a diagnosis of dissociative identity disorder. The nurse knows that which symptoms differentiate dissociative disorders from somatic symptom disorder? Select all that apply. 1. Flashbacks 2. Self-mutilation 3. Dissociation 4. Struggling with faith 5. Lack of connectedness

Answer: 1, 2

The nurse manager is providing an in-service to the staff nurses regarding personality characteristics associated with increased rates of suicide. Which characteristics will the nurse include in the teaching? Select all that apply. 1. Aggressiveness 2. Impulsivity 3. Passivity 4. Compulsivity 5. Assertiveness

Answer: 1, 2

The nurse is caring for a patient with Alzheimer disease (AD). A family member of the patient asks the nurse, "Is this disease genetic?" What is the nurse's best response? Select all that apply. 1. "Some forms of AD have a genetic pattern." 2. "Early-onset AD is more likely familial than late-onset AD." 3. "One-third to one-half of all AD may be the genetic form." 4. "One-quarter to one-third of all AD my be the genetic form." 5. "There is not any evidence of a genetic link with AD."

Answer: 1, 2, 3

The nurse is caring for a patient with a history of violent behaviors. Which nursing interventions are most likely to prevent the patient from responding with aggressive or violent behavior? Select all that apply. 1. Address the patient's anxiety as needed. 2. Determine the patient's coping mechanisms. 3. Ensure the patient's needs are met in a timely manner. 4. Assess the patient's family history of violent behaviors. 5. Avoid intervention with the patient if he or she is displaying aggression.

Answer: 1, 2, 3

The nurse is caring for a school-age child who is experiencing crisis. The child's mother tells the nurse that the child has started wetting the bed at night. Which statements by the nurse are the most appropriate regarding the best therapies for the child? Select all that apply. 1. "School-based interventions may help your child." 2. "Cognitive-behavioral therapy is most beneficial for your child." 3. "Interventions that support parental involvement may help your child." 4. "Cognitive therapy that addresses thought processes involved in crisis may help your child." 5. "Behavioral therapy to address the relationship between mood and behavior may help your child."

Answer: 1, 2, 3

The nurse is performing an initial suicide risk assessment. What questions will the nurse include in this assessment? Select all that apply. 1. "Do you have thoughts of suicide?" 2. "Do you have a way to harm yourself?" 3. "Do you have fantasies about hurting yourself?" 4. "Do you have thoughts about the consequences that result from suicide?" 5. "Do you have thoughts about how your family will react if you commit suicide?"

Answer: 1, 2, 3

) The nurse knows that which types of complementary and alternative therapy may be helpful for patients with dissociative identity disorder (DID)? Select all that apply. 1. Hypnosis 2. Art therapy 3. Music therapy 4. Dance therapy 5. Acupuncture

Answer: 1, 2, 3, 4

A 14-year-old patient has been raised from infancy in a series of foster homes and has difficulty forming significant and stable emotional connections. This increases the patient's risk for which responses or disorders? Select all that apply. 1. Anxiety 2. Suicidality 3. Drug abuse 4. Depression 5. Schizophrenia

Answer: 1, 2, 3, 4

The nurse is providing education to a family who is experiencing crisis due to divorce. The nurse emphasizes the importance of self-care and treatment of crisis. Which statements will the nurse include in the family teaching? Select all that apply. 1. "While every crisis is different, there are options that will help during this time." 2. "It is important to monitor for behavioral changes while coping with crisis." 3. "It may be beneficial to write in a journal to document stress exposures while coping with crisis." 4. "While every crisis is different, there are common emotions which occur while coping with crisis." 5. "It may be best to stay home from school or work during this time in order to avoid social interaction."

Answer: 1, 2, 3, 4

A grieving patient asks a nurse what he would get from participating in a grief support group. What benefits can the nurse include when responding? Select all that apply. 1. Social support 2. Connection to resources 3. Validation of experience 4. Direction on how to grieve 5. The opportunity to share his story

Answer: 1, 2, 3, 5

The nurse is caring for a patient with acute anxiety. What interventions are most beneficial for preventing escalation of anxiety to aggression? Select all that apply. 1. Provide needed food and drink. 2. Assist the patient without delay. 3. Show a calm, positive, friendly demeanor. 4. Express sympathy and concern for the patient. 5. Decrease environmental stimuli.

Answer: 1, 2, 3, 5

The nurse is participating in psychological debriefing of a patient who is experiencing a crisis. Which statements will the nurse include when providing education to the patient or family of the patient who is experiencing crisis? Select all that apply. 1. "Transportation is available if you cannot drive." 2. "You may want to use a calendar to help you track your response to the crisis." 3. "Do you have a spiritual leader that you would like me to contact for you?" 4. "The sedative that the health care provider prescribed is a common treatment." 5. "The relaxation techniques that the health care provider suggested are a common treatment." 

Answer: 1, 2, 3, 5

The nurse educator is teaching an in-service on the recognition of patient aggression within the hospital. One of the nurse participants is asked to classify her patient's behavior to determine if the patient is at risk for aggression. Which patient does the nurse classify as displaying manifestations that may lead to aggression? Select all that apply. 1. 47-year-old female who appears fearful and angry 2. 20-year-old male who is experiencing acute anxiety 3. 25-year-old female who is experiencing sadness regarding a death in the family 4. 75-year-old male who is expressing frustration due to a delay in hospital discharge 5. 36-year-old male who has expressed apprehension regarding his upcoming medical procedure

Answer: 1, 2, 4

The nurse in an emergency department is conducting mental health assessments. The nurse recognizes that which patients are at greatest risk for a suicide attempt? Select all that apply. 1. A 45-year-old with a personality disorder 2. A 19-year-old with a recent diagnosis of schizophrenia 3. A 35-year-old working mother who is brought in by her co-worker 4. A 22-year-old soldier recently returned from deployment in Afghanistan 5. A 15-year-old who sprained his ankle while camping with his church group

Answer: 1, 2, 4

The nurse is caring for a patient with aggressive behavior. The health care provider has ordered a selective serotonin reuptake inhibitor (SSRI). The nurse is providing patient education related to the medication when the patient asks, "Why is this being prescribed for me? I'm not depressed." What is the nurse's best response? Select all that apply. 1. "SSRIs are sometimes used to minimize anxiety." 2. "SSRIs are sometimes used to minimize impulsivity." 3. "SSRIs are sometimes used to improve coping skills." 4. "SSRIs increase serotonin levels, decreasing aggression." 5. "SSRIs decrease serotonin levels, decreasing aggression."

Answer: 1, 2, 4

The nurse is discussing the benefits of play therapy with the parents of a 4-year-old child. The nurse explains that play theory assists children with developing which skills? Select all that apply. 1. Expressing feelings 2. Working through conflicts 3. Interrupting patterned behavior 4. Improving problem solving skills 5. Improving eye-hand coordination

Answer: 1, 2, 4

The nurse is caring for a patient in crisis who has recently returned from military service in an active war zone. When initially assessing this patient, which concepts will the nurse apply regarding the type of crisis the patient is experiencing? Select all that apply. 1. Determining the client's adaptation to the crisis guides the priority nursing actions. 2. Determining the trauma category the client is experiencing guides the priority nursing action. 3. Providing the client with education regarding type I trauma related to his or her military service. 4. Providing the client with education regarding type II trauma related to his or her military service. 5. Determining the client's degree of trust in trusted authorities during his or her military service.

Answer: 1, 2, 4, 5

The nurse is caring for a patient suspected of having Alzheimer disease. The nurse knows that alterations in which areas can occur with Alzheimer disease? Select all that apply. 1. Memory 2. Executive function 3. Visual acuity 4. Language 5. Behavior and personality

Answer: 1, 2, 4, 5

Which statements by the patient indicate the patient may be experiencing intimate partner violence (IPV)? Select all that apply. 1. "My partner uses our children as messengers." 2. "My partner humiliates me in front of our friends." 3. "My partner gets upset at me for spending too much money." 4. "My partner will not allow my family to visit, and I cannot visit any of my friends." 5. "My partner gives me a weekly allowance and does not allow me to access our bank account."

Answer: 1, 2, 4, 5

A nurse at a long-term care facility is conducting an initial interview with a patient who has recently been diagnosed with Alzheimer disease. The patient is grieving the death of her spouse of 30 years. What are some appropriate interventions the nurse might consider? Select all that apply. 1. Ask the patient if she wants to talk about her recent losses. 2. Suggest that the patient might consider joining a grief support group at the facility. 3. Advise the patient that she will soon adjust to her new circumstances and feel much better. 4. Ignore the patient's losses since she probably doesn't remember them and it is better not to remind her. 5. Ask the patient if there are any ways in which the nurse could help the patient be more comfortable in her new surroundings.

Answer: 1, 2, 5

The patient presents at the health care provider's office at the urging of her spouse. Which statements by the spouse suggest to the nurse that the patient is in stage 2 of Alzheimer disease? Select all that apply. 1. "She sometimes forgets to take her medicine." 2. "All she does is lie in bed and cry." 3. "She's always been good at math, but she has trouble sometimes with things like counting the correct change." 4. "She'll ask me the same question several times in a row." 5. "Yesterday she wandered away from the house and was lost for hours."

Answer: 1, 3

When performing a suicide risk assessment, for which factors should the nurse assess based on an understanding of the psychiatric causal factor in suicide? 1. Anticipatory grief 2. Fearful anxiety 3. Acute illness 4. Increased productivity

Answer: 2 Explanation: 2. Anxiety has been implicated as a psychiatric causal factor in most research that has focused on the study of suicide. Specifically, anxiety that is fearful and filled with apprehension has been linked to high tendencies of suicide. Depression and decreased, not increased, productivity have been linked to an increased risk in suicide. Chronic disease, not acute disease, is linked to an increased risk for suicide. Anticipatory grief is not associated with increased risk for suicide.

A nurse is conducting a community risk assessment of the relationship between mental health and violence in the community. Which components would it be important for the nurse to include in the assessment? Select all that apply. 1. A method to determine the prevalence of violence within the community 2. A method to sample a diverse group of individuals across various communities 3. A method to determine the prevalence of mental disorders within the community 4. A method to quantify the number of individuals within the community who have mental illness and are currently being treated for the condition. 5. A method to quantify the number of individuals within the community who have mental illness and are not currently being treated for the condition.

Answer: 1, 3, 4, 5

The nurse is conducting research on violence in the community for a community health assessment. Which socioeconomic factors will the nurse include in the research? Select all that apply. 1. Age 2. Race 3. Poverty 4. Inequality 5. Substance use

Answer: 1, 3, 4, 5

The nurse manager knows that one of the nurses working on the unit has experienced several recent deaths. The nurse manager believes the nurse is not dealing with feelings of loss following these losses. Which behaviors by the nurse on the unit would indicate the nurse is having difficulty processing emotions? Select all that apply. 1. Complaining frequently 2. Talking with other nurses 3. Quickly becoming angry at others 4. Having difficulty prioritizing tasks 5. Sitting off to the side during staff meetings

Answer: 1, 3, 4, 5

The nurse taking care of a patient recently diagnosed with somatic symptom disorder knows that which biological symptoms are related to this disorder? Select all that apply. 1. Pain 2. Anxiety 3. Gastrointestinal distress 4. Paralysis 5. Blindness

Answer: 1, 3, 4, 5

A nurse is interviewing a patient who recently lost her spouse. Which symptoms reported by the patient would warrant a referral to a mental health provider? Select all that apply. 1. Prolonged insomnia 2. Crying 3. Severe weight loss 4. Anger 5. Suicidal ideation

Answer: 1, 3, 5

A patient experienced a miscarriage one week ago. She reports that her husband is very supportive but she feels very sad and is not sleeping or eating well. Why would the nurse suspect that her symptoms are those of grief rather than depression? Select all that apply. 1. The patient feels connected to others. 2. The patient cannot experience pleasure. 3. The symptoms are related to a specific loss. 4. The patient is not able to function normally. 5. The patient's symptoms are time limited.

Answer: 1, 3, 5

The school nurse is a member of the school's student support team. The team is meeting with parents of one of the football players to discuss his increasingly aggressive behaviors. Which risk factors will the nurse be prepared to discuss? Select all that apply. 1. Age 2. Ethnicity 3. Substance use 4. Parental occupation 5. History of head injury

Answer: 1, 3, 5

The nurse is caring for a patient diagnosed with dissociative identity disorder (DID). Which statements by the patient best describes the manifestations of this disorder? Select all that apply. 1. "I feel like my body is here but my mind is not." 2. "I have chronic pain, not a psychological problem." 3. "I can't really find any words to describe my feelings." 4. "I sometimes feel like I am floating in the air looking down at myself." 5. "I cannot recall the events that happened during certain periods of time."

Answer: 1, 4, 5

The nurse is caring for a patient with neurocognitive disease who is suspected of having depression. What is true regarding depression and neurocognitive decline? Select all that apply. 1. Depression may occur as a result of frustration associated with neurocognitive decline. 2. Depression is a universal finding in patients with neurocognitive decline. 3. Depression is easy to diagnose in those with neurocognitive decline. 4. Depression may occur as a result of the pathology of neurocognitive decline. 5. Depression is difficult to diagnose in those with neurocognitive decline.

Answer: 1, 4, 5

While performing a suicide assessment, the nurse asks the patient, "Have you ever thought of taking your own life?" What is the rationale for the nurse's question? Select all that apply. 1. It directly addresses the issue of suicide. 2. It causes the patient to think about suicide. 3. It gives the patient an idea about suicide methods. 4. It causes the patient to open up about other suicide attempts. 5. It alleviates the patient's anxiety about considering suicide.

Answer: 1, 4, 5

The nurse is caring for the following patients. Which patient should the nurse assess most carefully for suicide risk? 1. 16-year-old Asian female 2. 87-year-old Caucasian male 3. 72-year-old Hispanic female 4. 14-year-old African American male

Answer: 2 Explanation: 2. According to the Centers for Disease Control (CDC) and the American Association for Suicidology, individuals ages 85 and older commit suicide at a rate 36% higher than adults younger than 85. Also, Caucasians have the highest rate of death by suicide in the United States.

The nurse manager is providing education to staff regarding the prevention of workplace aggression. Which statement, made by a staff nurse, best displays that teaching has been effective? 1. "Cyberbullying does not typically occur in the hospital environment." 2. "Bullying may occur in social groups as well as professional groups." 3. "Type IV aggression may occur if a staff member is injured by a patient." 4. "Type I aggression may occur if a staff member is injured by another staff member."

Answer: 2 Explanation: 2. Bullying refers to repeated events or a pattern of behavior involving abuse or misuse of power. Although bullying typically is thought of as occurring in school or among children, bullying can occur in both social groups as well as professional groups. Cyberbullying may occur in the hospital environment by use of social media to threaten or intimidate peers. Type IV aggression occurs if a staff member is injured by a perpetrator who has a relationship to the staff member, but not to the organization or hospital. Type I aggression may occur when the perpetrator does not have a direct relationship to the staff member.

The school nurse recommends that the parents of a student seek help because the student is constantly in trouble and recently has set several small fires on school grounds. What condition is the school nurse suspecting? 1. Depression 2. Conduct disorder 3. Oppositional defiant disorder 4. Attention-deficit/hyperactivity disorder

Answer: 2 Explanation: 2. Children with a conduct disorder are more likely to fight, steal, vandalize, or have school problems. These are not signs of depression; however, the child with a conduct disorder may also be depressed. The most distinctive features of attention-deficit/hyperactivity disorder (ADHD) are inattention to the surrounding environment and hyperactivity and/or impulsiveness. The child with an oppositional defiant disorder may exhibit low self-esteem, minimal frustration tolerance, swearing, mood lability, and precocious use of tobacco, alcohol, or illegal drugs.

The nurse is caring for an older adult patient with a urinary tract infection (UTI). The patient points to the smoke alarm inside the room and asks the nurse, "Would you please turn on the radio?" For which alteration will the nurse assess the patient? 1. Agnosia 2. Delirium 3. Dementia 4. Pseudodementia

Answer: 2 Explanation: 2. Delirium typically is an abrupt, short-term change in mental state marked by confused thinking, disorientation, perceptual disturbances, agitation, and mood swings. Delirium results from an underlying medical condition, substance intoxication or withdrawal, exposure to a toxin, or other etiology. In this case, the patient is suffering from a UTI, which may be causing delirium. Dementia is a progressive disorder characterized by gradual loss of cognitive functioning. Pseudodementia is characterized by cognitive changes that arise secondary to depression. Agnosia, is the loss of sensory ability to recognize objects, and is a manifestation of Alzheimer disease.

The nurse is caring for a patient with moderate Alzheimer disease (AD). The health care provider has ordered donepezil (Aricept) for the collaborative treatment of the patient's disease. What medication teaching will the nurse include to both the patient and patient's family? 1. "The medication should be taken twice daily, once in the morning and once at night." 2. "The dose will be started low and will be gradually increased until the medication is no longer helpful." 3. "The medication should be taken three times daily with every meal." 4. "The dose will be started high and will be gradually decreased to make sure that side effects from the medication are tolerable."

Answer: 2 Explanation: 2. Donepezil (Aricept) is a cholinesterase inhibitor (ChEI), used in the treatment of moderate-to-severe AD. Dosage of this medication should start low and gradually be increased until side effects are no longer tolerable or the medication is no longer beneficial. Donepezil should be taken once daily in the evening.

A nurse is providing community mental health services to families identified as at risk for attachment disorder. What treatment might a nurse consider as most effective? 1. Mindfulness education 2. Parenting skills education 3. Brief solution-focused therapy 4. Cognitive-behavioral therapy

Answer: 2 Explanation: 2. Early attachment relationships appear to help shape early mental health in children and adolescents and parenting skills can help parents provide a healthy psychological foundation to foster self-confidence and calm to minimize fears and rejection. Mindfulness education teaches stress reduction. Brief solution-focused therapy is therapy directed at achieving a specific goal. Cognitive-behavioral therapy addresses dysfunctional thoughts, emotions, and behaviors.

A parent tells the nurse that her brother has Tourette syndrome and she is concerned that her five-year-old son may be at risk for the same disorder. Which is the most appropriate reply? 1. There is no known genetic association in Tourette syndrome. 2. There may be a genetic predisposition for developing Tourette syndrome. 3. A person whose uncle has Tourette syndrome will definitely develop the condition. 4. We do not have any information on the hereditary factors associated with Tourette syndrome.

Answer: 2 Explanation: 2. Genetic associations have been found in Tourette syndrome. The impact of environmental effects, heterogeneity, and other factors complicate what this means for diagnosis and treatment of children with this disorder, and no definite cause-effect relationship has been determined. Advances in genetic technology have implicated genetic associations in Tourette syndrome.

A 7-year-old patient tells the nurse, "I did bad things today," and the nurse responds, "Tell me about the bad things you did today." What is the nurse doing to connect to the child's experience? 1. Talking about the child's problem behavior. 2. Using the child's own language to engage with him. 3. Asking for specific information about the child's activity. 4. Repeating what the child said to reflect the child's statement back to him.

Answer: 2 Explanation: 2. If a child uses certain language to describe a feeling or experience, the nurse should attempt to use that language in further understanding the child's experience. The point of the nurse's response is not to address the child's "bad behavior," but to discuss whatever subject the child introduced. The nurse's open-ended response allows the child to follow his or her own thoughts rather than provide specific information. The nurse is not simply reflecting the child's experience but stimulating further discussion.

A nurse is conducting a follow-up assessment on a patient who lost his best friend several months ago. What patient statement would indicate that interventions have been effective? 1. "I just can't get over it." 2. "I think I'm sleeping better lately." 3. "I don't care about my loss anymore." 4. "I think that I am fine and don't really need treatment."

Answer: 2 Explanation: 2. Improved sleep in the patient who is grieving is an indication that interventions are helping. The patient who reports "I just can't get over it," may not be benefitting from interventions. The patient who says "I don't care" may be exhibiting denial or depression and may require further assessment. The patient who does not want treatment may be experiencing reluctance rather than recovery.

A nurse has traveled overseas to provide relief for a community experiencing crisis after a natural disaster. Which concept will guide the nurse in planning care for these individuals? 1. Crisis is a universal human experience with manifestations similar in all cultures. 2. Interventions should be centered on the involvement of local community leadership. 3. Assessment of abnormal expressions of emotional pain should be the nurse's priority. 4. Interventions should be centered on the treatment of posttraumatic stress disorder (PTSD).

Answer: 2 Explanation: 2. In intercultural situations, the nurse must provide culturally competent care with interventions centered on the involvement of local community leadership. How individuals perceive crisis can vary among cultures, as can manifestations. Local community leadership will have the greatest information about resources available locally and can provide valuable information on what community members will perceive as their greatest needs. How individuals express pain or respond to trauma may also vary, and nurses should work with members of the community to ensure they provide culturally competent care and not assess individual patients based solely on Western norms.

The nurse is planning care for a patient who is experiencing a crisis. The patient tells the nurse, "I feel out of control, and I can't seem to make any decisions." Which nursing action will best promote effective interventions for this patient? 1. Identifying the patient's level of grief 2. Identifying the origin of the patient's crisis 3. Increasing communication with the patient's significant others 4. Motivating the patient and family to take significant action in relationships

Answer: 2 Explanation: 2. In order to promote effective interventions for a patient experiencing crisis, the most effective intervention is identifying the origin of the patient's crisis. Once the nurse can determine the cause of the patient's crisis, the nurse can then individualize care for the patient. While the other answer choices may be appropriate nursing interventions, these do not best promote effective interventions for the patient.

Which statement made by the patient indicates the patient is experiencing spiritual distress? 1. "Who is responsible for this?" 2. "Why did this happen to me?" 3. "What should I do about this?" 4. "Who will take care of this problem?"

Answer: 2 Explanation: 2. Individuals must come to their own explanations and answer the question Why? The theme of the "unfairness" of life is common in spiritual distress. Blaming is not an indication of spiritual distress. Questions that look to a solution do not indicate spiritual distress.

The nurse is caring for a male patient who is experiencing a crisis. In considering the plan of care, which factor will the nurse take into account? 1. Men are less likely to resist help during times of crisis. 2. Men are more likely to resist help during times of crisis. 3. Men usually access intervention only when the acute crisis has ended. 4. The most successful intervention for men during times of crisis is individual psychotherapy.

Answer: 2 Explanation: 2. Men are far more likely to resist help during a time of crisis because help-seeking behaviors may challenge social norms of masculinity and induce a sense of vulnerability. Men usually access intervention only when in acute crisis; for this reason, it is critical to initiate crisis intervention within 24 to 48 hours of initial contact. The most successful interventions for men include the utilization of peer-led men's support groups, not individual psychotherapy.

A 17-year old-patient recently lost her mother. At her annual physical examination, the patient tells the nurse she will not be able to attend the residential college she had planned for because her responsibilities with her siblings at home have increased. Why will the nurse assess the patient for signs and symptoms of depression? 1. All adolescents suffer from depression. 2. Multiple losses increase the likelihood of depression 3. Lack of support increases the likelihood of depression. 4. Pressure to function increases the likelihood of depression.

Answer: 2 Explanation: 2. Multiple losses overwhelm usual coping mechanisms and place the individual at risk for depression. Although adolescents are at increased risk of depression, not all adolescents suffer from that condition. There is no indication that this patient is experiencing a lack of support. Pressure to function is not a significant indicator of depression.

Which nursing technique is appropriate for therapeutic interaction with a patient who has been diagnosed with Alzheimer disease? 1. Setting strict time limits and rephrasing misunderstood questions. 2. Encouraging verbal and nonverbal communication while maintaining a calm demeanor. 3. Correcting errors made by the patient and speaking in a loud, clear voice. 4. Using multiple memory cues and giving several directions at once.

Answer: 2 Explanation: 2. Nonverbal communication will become more prominent as verbal communication skills decline. A calm demeanor will reassure the patient and allow for a response without sensory overload. Correcting errors by the patient, speaking in a loud voice, using multiple memory cues, setting time limits, and rephrasing questions may overstimulate and increase the patient's frustration and anxiety.

The nurse has determined that a parent is experiencing chronic sorrow following the diagnosis of her child with cerebral palsy. What is an appropriate response for the nurse? 1. Suggest the possibility of residential care. 2. Provide information about support services and groups. 3. Caution the parent not to neglect the other children in the family. 4. Suggest that the parent work to disengage from the emotional intensity of the experience.

Answer: 2 Explanation: 2. Nurses can encourage hope in parents experiencing chronic sorrow by keeping them informed and by offering information about support groups and counseling. Suggesting disengagement does not help resolve the parent's ongoing sorrow. Being critical or offering parenting advice will not engage the parent with the nurse. Unsolicited suggestions do not provide appropriate support.

The nurse is caring for a patient who is verbally aggressive. What is the nurse's best response to the patient's behavior? 1. "Why are you so mad at me?" 2. "This behavior is unacceptable. I am here to help you." 3. "If you continue with this behavior, I will have to restrain you." 4. "I am going to call your health care provider for medication to calm you down."

Answer: 2 Explanation: 2. Nurses must convey a sense of confidence and competence in their ability to provide care. This can be difficult in situations in which a patient becomes angry and hostile. However, it is important for the patient to see staff as composed and able to provide support and care, despite difficult behaviors that arise. The nurse is displaying confidence when stating, "This behavior is unacceptable. I am here to help you." This statement sets boundaries between the nurse and patient, as well as using techniques of therapeutic communication. Asking the patient why the patient is mad at the nurse does not convey confidence. The other answer choices are threatening, inappropriate, and do not reflect confidence in the nurse's ability to care for the patient.

A hospice nurse realizes that her work exposes her to a lot of emotional suffering. How could she respond effectively to these pressures? 1. Take courses on grieving. 2. Organize a peer support group. 3. Take anti-depressant medications. 4. Talk to her patients about her feelings.

Answer: 2 Explanation: 2. Nurses who are continuously providing support for patients can benefit from peer support for their own emotional responses. Although courses provide important information, they are not intended to provide psychological support. Antidepressant medications are indicated for clinical depression, not job stress. A nurse should not use patients to assist them with their own emotional needs.

A nurse is planning care for a patient who is experiencing a situational crisis. What is the most effective way for the nurse to plan for the patient's crisis intervention? 1. Organized with follow-up 2. Based on complete assessment 3. Focused on long-term problems 4. Developed prior to meeting with the patient

Answer: 2 Explanation: 2. Nursing care is based on complete assessments. Thus, a plan cannot be developed prior to meeting with the patient. The time frame, whether short-term or long-term, and the need for follow-up, will be determined by the findings of the assessment.

The nurse taking care of a patient with a diagnosis of dissociative identity disorder is developing a plan of care. The nurse knows that which nursing diagnoses relate to the patient's diagnosis? 1. Nutrition, Impaired 2. Parenting, Impaired 3. Body Image, Disturbed 4. Pain, Related to violence

Answer: 2 Explanation: 2. Nursing diagnoses for patients with dissociative disorder are based on safety level and patient's current intensity of dissociation and amnesia. Patients who are parents may experiencing impairment of their parenting abilities as a result of the disorder. Other appropriate nursing diagnoses include: Suicide, Risk for; Violence: Self-Directed, Risk for; Self-Mutilation; Personal Identity: Disturbed; Fear; Hopelessness; and Powerlessness. All other answer choices are not related to dissociative disorder.

A nurse is working with a 16-year-old tornado survivor who is diagnosed with posttraumatic stress disorder (PTSD). What therapy might she use to emphasize positive outcomes of trauma? 1. Somatic experiencing 2. Posttraumatic growth (PTG) 3. Cognitive-behavioral therapy (CBT) 4. Eye movement desensitization and reprocessing (EMDR)

Answer: 2 Explanation: 2. PTG theory emphasizes the transformative potential of one's experiences with highly stressful events and circumstances, noting that positive growth experiences may be optimal during late adolescence. Somatic experiencing addresses PTSD by focusing on the body's remembered sensations. CBT has been found to be an effective treatment intervention for PTSD, but it does not emphasize the positive growth potential. Eye movement desensitization and reprocessing (EMDR) is a fairly new, nontraditional type of psychotherapy that remains controversial among some health care professionals.

A patient has had what appeared to be an epileptic seizure; however, the patient's MRI and EEG results that do not show seizure activity. After a thorough assessment and appropriate tests by the patient's health care professional, the nurse begins to suspect which psychological disorder? 1. Factitious disorder 2. Conversion disorder 3. Illness anxiety disorder 4. Somatic symptom disorder

Answer: 2 Explanation: 2. Patients who have symptoms of conversion disorder experience one or more changes in voluntary motor or sensory function, changes that are not recognized as neurologic or medical in origin. Some patients may experience symptoms that mimic seizure. Factitious disorder is characterized by patients falsifying an illness. Somatic symptom disorder refers to emotional distress that exhibits through somatic or physiological symptoms. Illness anxiety disorder refers to patients who experience preoccupation with having an illness, though there are typically no physical symptoms.

The nurse is caring for a patient with moderate Alzheimer disease. What nursing intervention best promotes communication? 1. Keep a consistent daily routine. 2. Limit the number of food choices. 3. Give the patient step-by-step instructions. 4. Correct the patient when experiencing a hallucination.

Answer: 2 Explanation: 2. Patients with Alzheimer disease often communicate through behavior. Individuals with Alzheimer disease tend to have short attention spans, and limiting the number of food choices decreases the patient's frustration, improving communication. Keeping a consistent daily routine and giving the patient step-by-step instruction are appropriate interventions for a patient with Alzheimer disease; however, these do not promote communication. The nurse should not argue or correct a patient when the patient is experiencing a hallucination.

A 70-year-old patient presents to the health care provider's office complaining of tremors and memory problems. The patient says "I just can't get around like I used to. It feels like it takes forever to get started." Which disorder will the nurse suspect? 1. Traumatic brain injury 2. Parkinson disease 3. Alzheimer disease 4. Human Immunodeficiency Virus

Answer: 2 Explanation: 2. Patients with Parkinson disease experience tremors, postural instability, memory impairment, and cognitive and motor slowing. Tremors and motor slowing are not typically associated with Alzheimer disease, dementia due to HIV, or traumatic brain injury.

A patient diagnosed with dissociative identity disorder is in the emergency department after attempting suicide. After a thorough assessment the nurse determines the attempted suicide was in response to which event? 1. Drug abuse and living homeless on streets 2. Childhood sexual abuse by biological father 3. Unidentified continuous abdominal and neck pain 4. Multiple somatic and psychological issues over the past 6 months

Answer: 2 Explanation: 2. Patients with dissociative identity disorder have sustained horrific physical and psychological abuse over time. These events lead to the patient experiencing multiple ego states that help the patient survive the trauma. Suicidal ideation is common among patients with this disorder. The other answer choices are not indicative of dissociative identity disorder.

The home health nurse is assigned to a new patient with a major neurocognitive disorder. Which will the nurse include in the initial assessment when visiting the patient at home? Select all that apply. 1. Eating habits 2. Ability to pay bills 3. Ability to shower and shave 4. Internet use 5. Medication adherence

Answer: 2 Explanation: 2. Patients with neurocognitive disorders experience decline in functioning across the wellness domains, including their ability to manage finances, recognize safety risks, and care for themselves independently. The nurse will assess patients in these areas and provide referrals and plan interventions as appropriate to ensure patients are able to maintain good nutrition and hygiene, take their medications safely, and have the financial resources that they need. Use of the internet is not a priority for assessment.

The emergency department nurse educator is providing an in-service to the nursing staff on recognizing the signs and symptoms of interpersonal violence (IPV) and rape. Which assessment finding will the educator include in the teaching? 1. Sores around the mouth, brittle hair 2. Multiple bruises, abrasions at various stages of healing 3. Acting-out behaviors, disobedience, trouble with the law 4. Poor eye contact, depressed mood, unwillingness to give history data

Answer: 2 Explanation: 2. Physical abuse is the non-accidental use of physical force that results in bodily injury, pain, or impairment. Multiple bruises and abrasions at various levels of healing are signs that the patient may have been subjected to physical abuse. Acting-out behaviors are more consistent with antisocial personality disorder. Poor eye contact, depressed mood, and withdrawal behaviors are more consistent with a diagnosis of depression. Sores around the mouth and brittle hair may indicate an eating disorder.

In order to prevent suicide, the nurse is learning about recognizing protective measures in patients displaying hopelessness. Which patient will the nurse recognize as displaying external protective measures? 1. The patient who is passive during a dispute. 2. The patient who requests assistance when needed. 3. The patient who remains calm during an argument. 4. The patient who displays problem-solving capabilities.

Answer: 2 Explanation: 2. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. There are internal and external protective measures. The patient with external protective measures relates to others and can request assistance when needed. The patient who is able to solve problems, think through conflict, and handle disputes without violence is displaying internal, not external protective measures.

The nurse manager is reviewing risk factors for workplace aggression during a monthly staff meeting. The nurse manager includes risk factors for aggression related to the psychiatric patient population. Which statement by the staff nurse indicates that teaching has been effective? 1. "Patients who are being treated for depression have an increased risk for aggression." 2. "Patients who have been diagnosed with dementia have an increased risk for aggression." 3. "Patients who are receiving group therapy for somatic symptom disorders have an increased risk for aggression." 4. "Patients who are receiving cognitive-behavioral therapy for eating disorders have an increased risk for aggression."

Answer: 2 Explanation: 2. Risk factors for aggression related to the patient population include dementia, psychosis, mania, substance use or withdrawal, and personality disorders. Depression, somatic symptom disorder, and eating disorders do not present an increased risk for aggression related to the patient population.

The nurse is caring for a patient with vascular dementia. Based on the neurobiology of this condition, what is the nurse's primary concern when caring for this patient? 1. Pain 2. Safety 3. Communication 4. Level of consciousness

Answer: 2 Explanation: 2. Safety is the primary concern for nurses at all times. However, this is especially true for the client with vascular dementia. In vascular dementia, patients suffer the equivalent of small strokes that destroy many areas of the brain. Onset is abrupt, resulting in rapid changes to functioning. The patient may have an altered gait and weakness of the limbs, increasing the risk for falls. Pain is not a common feature of vascular dementia. While the nurse will assess communication and level of consciousness, these are not the primary concerns when caring for a patient with vascular dementia.

The nurse is caring for a patient whom the nurse suspects is a victim of intimate partner violence (IPV). What screening question made by the nurse is most appropriate? 1. "Can you tell me how you got your injuries?" 2. "Can you tell me if it is safe for you to go home?" 3. "Can you tell me what you know about intimate partner violence?" 4. "Can you tell me what your spouse was doing when you sustained your injuries?"

Answer: 2 Explanation: 2. Screening is one way that nurses can help to provide information and resources to a person who may be suffering IPV. The most appropriate way to screen for IPV is the use of direct questions about the violence. The most appropriate question is, "Is it safe for you to go home?" All the other questions are not as direct, and they do not get at the priority nursing action, which is to assess the safety of the patient.

A nurse is working with a six-year-old diagnosed with OCD. What medication might the nurse expect would be prescribed for this patient? 1. Clomipramine (Anafranil) 2. Sertraline (Zoloft) 3. Methylphenidate (Ritalin) 4. Olanzapine (Zyprexa)

Answer: 2 Explanation: 2. Sertraline (Zoloft) has FDA approval for treating OCD in children 6 years and older. Specific recommendations cannot be made for the use of clomipramine (Anafranil) in pediatric patients under the age of 10. Methylphenidate (Ritalin) and olanzapine (Zyprexa) are not indicated for OCD.

A nurse working in a disaster recovery center is interviewing a patient whose home and business were destroyed in a tornado. The patient is determined to recover and rebuild. Which statement by the patient would indicate the need for referral to a social worker? 1. "I almost feel as though God has abandoned me." 2. "I don't know where to begin to get back on my feet." 3. "I don't think I can go back to my old work since the nerves in my hand were damaged." 4. "No matter how hard I try, I can't get to sleep at night and I seem to be crying most of the time."

Answer: 2 Explanation: 2. Social workers have knowledge and experience with linking patients and families to other financial and health resources that can assist in recovery. Clergy and spiritual leaders can help address spiritual distress. Occupational therapists address specific issues with living and work skills, which may be necessary for patients who have damaged extremities. Mental health specialists address mental health conditions such as depression and anxiety.

A kindergarten teacher refers a student to the school nurse because he appears unable to engage in play with the other children and insists on playing alone with a particular toy. He also shows delayed language development. What disorder might the nurse suspect? 1. Conduct disorder 2. Autism spectrum disorder (ASD) 3. Posttraumatic stress disorder (PTSD) 4. Attention-deficit/hyperactivity disorder (ADHD)

Answer: 2 Explanation: 2. The core symptoms of ASDs are impairment of social interactions and communication, and restricted, repetitive behaviors and interests. Conduct disorder is defined by a relatively persistent pattern of multiple antisocial behaviors during childhood and adolescence. PTSD is a response to trauma that often involves recurring, distressing dreams related to the event. Although children with PTSD may withdraw from others and disengage from activities, they do not typically exhibit language delays. Core symptoms of ADHD fall into three categories: inattention, hyperactivity, and impulsivity.

The nurse is caring for a patient who is making obscene gestures to other staff members and is raising his voice in protest of an ordered test. What is the nurse's best action? 1. Determine the patient's level of anxiety. 2. Determine what basic patient needs are not being met. 3. Review the patient's chart for previous violent episodes. 4. Contact the health care provider regarding the patient's actions.

Answer: 2 Explanation: 2. The key concept to managing aggressive behavior is to identify the behavior warning signals. The patient is displaying escalating aggression by making obscene gestures and raising his voice. Escalation of aggression most often occurs when the patient's basic needs are not being met. The most appropriate action by the nurse is to determine what basic patient needs are not being met, in order to stop the escalation of aggression. The patient is displaying symptoms of escalating aggression from anxiety; therefore, determining the level of anxiety is not the best action, as the nurse must act in order to prevent further escalation. Reviewing the patient chart does not help to prevent the patient from becoming aggressive. Contacting the health care provider is not the best action because the nurse must act independently and quickly in order to prevent the escalation of aggression.

The parent of a patient in physical restraints asks the nurse, "Why is my son tied down? He wouldn't hurt anyone." What is the nurse's best response? 1. "The restraints are placed to control his behavior." 2. "The restraints are placed to prevent harm to him and others." 3. "The restraints are placed because he was angry to the staff." 4. "The restraints are placed to keep him from falling off the bed."

Answer: 2 Explanation: 2. The nurse's best response is to tell the parent that the patient is in restraints to prevent the patient from harming himself or others. Restraints are not used simply because a patient was angry or to control behavior. All other less-invasive measures must be used prior to placing restraints and the patient must be a threat to self or others. Also, restraints are not used solely to keep a person from falling off the bed.

A patient tells the nurse, "I don't want to go home. I'm afraid my spouse will hurt me again." What is the nurse's best response? 1. Invite the abuser to the assessment session. 2. Avoid pressuring the patient to leave the abuser. 3. Acknowledge the patient's inability to change the situation. 4. Ensure not to ask direct questions about abuse, as this will intimidate the patient.

Answer: 2 Explanation: 2. The patient is a victim of interpersonal violence (IPV). The nurse should not pressure the patient to leave, as it may be more dangerous for the patient to leave at this time, and the patient may have to wait until an opportunity arises. The patient should not be discouraged from efforts to prevent future violence but should be encouraged to look for opportunities to change the situation by developing a safety plan. Having the abuser present may prevent the patient from talking openly with the nurse. The nurse should ask direct questions as appropriate when engaging in therapeutic communication with the patient.

The nurse is observing several patients who are in the activity room of the inpatient psychiatric facility. The nurse notices that one of the patients begins to get upset, raising her voice, pacing the room, and standing with clenched fists. What is the nurse's priority action? 1. Reorient the patient to person, place, and time. 2. Remove other patients from the room to provide more space. 3. Call the health care provider to obtain an order for anti-anxiety medication. 4. Call security and promptly isolate the patient and apply physical restraints.

Answer: 2 Explanation: 2. The patient is displaying increased anxiety and aggression. Anxiety and agitation tend to escalate when there is an audience, so removing other patients to another area of the unit is a useful intervention. Removing other patients also provides safety for both the patient who is experiencing anxiety and for the other patients in the room. The patient is not displaying symptoms of altered level of consciousness or disorientation, so the primary nursing action is not to reorient the patient. Calling the health care provider for pharmacological intervention would be appropriate only after the nurse fails to achieve the desired outcome using less restrictive independent interventions. Applying physical restraints is a last resort that would not be used as a primary intervention.

Which statement by a nurse would indicate a nonjudgmental attitude toward violence and abuse? 1. "Many women who have sex when drunk tend to perceive it as rape." 2. "I admitted an 18-year-old for a suicide attempt following a date rape." 3. "Many adolescents call it rape when they don't enjoy a sexual experience." 4. "Parents should not allow their children out at the night; this is when most date rapes happen."

Answer: 2 Explanation: 2. The statement, "I admitted an 18-year-old for a suicide attempt following a date rape" is objective and nonjudgmental. The other statements express personal bias or assume victims are to blame for their own rapes. These are subjective judgments that engage in victim blaming and are not therapeutic

A patient whose home was destroyed by fire is in a disaster recovery area. A nurse tells the patient, "I know just how you feel. We had a fire in our home when I was a little girl." What type of communication is the nurse using? 1. Active listening 2. Disabling communication 3. Informational communication 4. Therapeutic communication

Answer: 2 Explanation: 2. There are several ways that the nurse can block communication or disable the patient's ability to participate, including making comparisons. Active listening requires the listener to feedback what they hear to the speaker. Informational communication provides the patient with data about what is happening and what to expect. Therapeutic communication is a method of interacting that focuses on the physical and emotional well-being of a patient.

When assessing a patient's suicidal ideations and level of risk, which question most appropriately conveys empathy? 1. "Do you have any firearms?" 2. "What struggles in your life are upsetting you?" 3. "Do you ever feel like you want to hurt yourself?" 4. "Is there anything you could do now to make yourself feel better?"

Answer: 2 Explanation: 2. When assessing a patient's suicidal ideations and level of risk, the nurse will ask questions that either establish empathy or directly assess the patient's suicide ideation. Asking the patient, "What struggles in your life are upsetting you?" best conveys empathy by the nurse. Asking if patients own firearms, feel like they want to hurt themselves, or if there is anything that will make them feel better are appropriate questions to ask; however, these do not convey empathy.

The nurse assesses a patient and finds several old and fresh bruises in the abdominal area, as well as signs of malnutrition. What is the most appropriate question for the nurse to ask? 1. "Are you dieting?" 2. "Has someone been hurting you?" 3. "Do you have an alcohol problem?" 4. "Have you had any falls lately?"

Answer: 2 Explanation: 2. When the nurse suspects abuse, it is important to ask direct questions, such as asking if the patient has been hurt by someone. Asking if the patient is dieting or has fallen implies that the nurse has made assumptions about the cause of the injuries. The question about an alcohol problem carries with it a suggestion that the patient is to blame for the injuries.

The nurse is caring for a patient who is active duty military. The nurse suspects the patient may be suicidal. According to current research on laboratory values and suicide, which action by the nurse would be most appropriate? 1. Review the patient's vitamin K level 2. Review the patient's vitamin D level 3. Review the patient's serum calcium level 4. Review the patient's serum potassium level

Answer: 2 Explanation: 2. While further research is still needed, research has found a relationship between completed suicide and low vitamin D levels. While reviewing the other laboratory values are not inappropriate, these actions do not reflect the current research on laboratory values and suicide.

The nurse understands that the patient with somatic symptom disorder may have an increased sensitivity to pain. This explanation of the patient's symptoms is based in which domain? 1. Genetic domain 2. Biologic domain 3. Humanistic domain 4. Psychological domain

Answer: 2 Explanation: Holistically, in nursing, there are five domains of wellness: biological, psychological, sociological, cultural, and spiritual. Research has shown that patients with somatic symptom disorder and its related disorders express symptoms such as pain and other somatic experiences through their body. This heightened sense of pain and other normal body sensations occurs in the biological domain.

The stepfather of a child diagnosed with a conduct disorder wants to know the reason for including him in family therapy sessions. What will the nurse tell the stepfather is the goal of family therapy? 1. Help the child relive past events and related feelings. 2. Increase the probability that the child's mental health will improve. 3. Speak for the child so the parents can become more aware of the child's potential. 4. Provide an opportunity for the parents to interact with their child in a safe environment.

Answer: 2 Explanation: 2. The goal of family therapy is to increase the likelihood that improvements in the child's mental health will occur. Involving step-parents in family therapy builds support in the home for these gains with consistent and sustained family patterns. Reliving past events and related feelings may occur as part of play therapy. Speaking for the child is not a goal of family therapy. Providing a safe environment for interaction is another aspect of increasing the likelihood that improvements will occur; however, it is not a goal of family therapy.

The nurse is caring for a 40-year-old patient suspected of having a somatic symptom or related disorder. Which symptoms within the psychological domain would suggest that the patient does not have a somatic symptom or related disorder? Select all that apply. 1. Hallucinations 2. Compulsions 3. Flashbacks 4. Irritability 5. Withdrawal

Answer: 2, 3

A patient in a residential treatment facility who was behaving aggressively was prescribed risperidone. How should this patient be monitored? Select all that apply. 1. IQ test 2. Lab panels 3. Physical exam 4. Baseline EKG 5. Pulmonary function evaluation

Answer: 2, 3, 4

The graduate nurse is researching methods for maintaining resilience in stressful clinical situations. Which actions would the nurse employ, based on the core concept of resilience? Select all that apply. 1. Reading professional journals and maintaining continuing education 2. Choosing to work at a facility where the nurse enjoys the environment. 3. Participating in a staff debriefing after a difficult interaction in the unit 4. Joining a unit-based council that focuses on quality improvement 5. Teaching a seminar to a group of peers on a topic that the nurse enjoys

Answer: 2, 3, 4

The nurse educator is planning various seminars for the staff nurses regarding care of the patient in physical restraints. Which essential nursing interventions will the educator include in the staff seminar? Select all that apply. 1. Turn patient every 4 hours. 2. Toilet the patient as needed. 3. Assign one-to-one observation. 4. Assess skin integrity every hour. 5. Assess circulation, sensation, and movement every 6 hours.

Answer: 2, 3, 4

The nurse manager is preparing a teaching session on suicide for a group of novice nurses. What will the nurse manager include in the teaching? Select all that apply. 1. Women commit suicide more than men. 2. Men commit suicide more than women. 3. Women have a higher rate of attempted suicide. 4. Older adults commit suicide more than younger adults. 5. Younger adults commit suicide more than older adults.

Answer: 2, 3, 4

A nurse educator is providing a review course for staff nurses regarding the impact and risk factors for situational crisis among the psychiatric patient population. The educator asks one of the staff nurses to provide a clinical example of a patient at increased risk for situational crisis. Which statements made by the staff nurse indicates that teaching has been effective? Select all that apply. 1. "The teenager who is graduating high school in 3 weeks." 2. "The older adult who recently immigrated from Mexico." 3. "The middle-aged adult who just received a diagnosis of depression." 4. "The young adult who is arrested and incarcerated for driving under the influence." 5. "The young adult who is experiencing psychosis after giving birth to a healthy baby."

Answer: 2, 3, 4, 5

A nurse is working with the family of a child diagnosed with leukemia. Which nursing interventions are most appropriate? Select all that apply. 1. Offer financial advice 2. Provide active listening 3. Offer referral to a spiritual advisor 4. Work with physicians to provide information 5. Provide information on available support groups

Answer: 2, 3, 4, 5

The nurse is caring for an older adult patient who presented to the emergency department with delirium. For which conditions will the nurse assess the patient? Select all that apply. 1. Drug abuse 2. Infection 3. Drug toxicity 4. Hypoxemia 5. Fluid volume deficit

Answer: 2, 3, 4, 5

The advanced practice nurse is caring for a patient in an outpatient clinic who has expressed thoughts of suicide, but who does not have a plan or means in place. The patient tells the nurse, "I sometimes think it would be easier for me to just go to sleep and never wake up. But I don't hurt myself because I love my children too much." Which nursing interventions are most appropriate for this patient? Select all that apply. 1. Place the patient on constant observation for safety. 2. Teach the use of the National Suicide Prevention Lifeline. 3. Admit the patient to the behavioral health hospital immediately. 4. Encourage the patient to use internal and external support systems. 5. Be aware that the patient is likely to reject any attempt at intervention, including teaching.

Answer: 2, 4

A 44-year-old patient is in the middle of a divorce and just lost his job. Which factors that might affect the patient's resilience will the nurse assess? Select all that apply. 1. Job skills 2. Coping resources 3. Financial resources 4. Supportive relationships 5. Prior experience with successful resolution of loss

Answer: 2, 4, 5

A nurse has been hired to work in a milieu management program. With which techniques should the nurse be familiar? Select all that apply. 1. Hypnotherapy 2. Reinforcement 3. Psychoanalysis 4. Pattern interruption 5. Affect management

Answer: 2, 4, 5

The nurse manager is teaching the staff nurses in the emergency department about violence in health care settings. What information will the nurse include when teaching about hospital risk factors that increase risk of violence? Select all that apply. 1. High census levels 2. Low staffing levels 3. Characteristics of staff 4. Characteristics of services delivered 5. Waiting times for services delivered

Answer: 2, 4, 5

The student nurse is caring for a patient with Alzheimer disease. The student asks the nurse preceptor, "What types of medications may be used to treat Alzheimer disease?" What is the nurse's best response? Select all that apply. 1. Anticholinesterase agonist 2. Cholinesterase inhibitor 3. Anticholinergic inhibitor 4. NMDA receptor agonist 5. NMDA receptor antagonist

Answer: 2, 5

A parent reports that her nine-year-old son experiences nocturnal bed-wetting several times each month. The parent wants to know if this problem will cure itself. Which is the most appropriate response by the nurse? 1. "This problem responds only to treatment with family therapy." 2. "Unless you consider using medications, the problem will continue." 3. "Most children stop wetting the bed at night by the time they reach adolescence." 4. "Most cases of enuresis are a result of organic causes and require medical treatment."

Answer: 3 Explanation: 3. Although as many as 10% of seven-year-olds wet the bed at night, there is a high remission rate, with only 1% to 2% of adolescents still experiencing nocturnal enuresis. Although family therapy and support may be indicated in some cases, it is not the only treatment alternative. Medications may be used to temporarily control bed-wetting, but they do not stop it. Most causes of enuresis are not organic.

A school nurse wants to design an in-school program to help improve the mental health of the students. What topic would be an appropriate choice that would affect the most students? 1. Weight control 2. Drug abuse prevention 3. Collaborative antibullying 4. Effective studying techniques

Answer: 3 Explanation: 3. Approximately 30% to 40% of children and adolescents are bullied or bully others in their school years. A proactive, collaborative approach appears to have the greatest outcomes on changing bullying behaviors. Weight control, although it may have some self-esteem repercussions, is not a mental health intervention for a significant population. Drug abuse prevention is an important mental health intervention, but it would not affect the most students, as approximately 8% of the adolescent population estimated to use illicit drugs. Effective studying is an academic, not a nursing, intervention.

During a therapy session an 11-year-old patient tells the psychiatric advanced practice nurse that he wants to leave. The nurse wants to understand what created this feeling. How might she respond to the patient's statement? 1. "Is there somewhere you want to go?" 2. "I guess you're upset about something." 3. "What happened to make you feel the need to leave?" 4. "Why don't you just sit down for a minute so we can talk some more?"

Answer: 3 Explanation: 3. Asking about what happened acknowledges the patient's need, and using an open-ended question is more likely to elicit a meaningful response. Asking about where the patient may want to go pins him down and limits his responses. Suggesting that the patient is upset makes an assumption that closes off discussion. Suggesting that the patient stay and talk addresses the nurse's need without addressing the patient's need.

When providing staff education regarding basic safety monitoring and status reporting of a patient in crisis, what will the charge nurse include? 1. Basic coping skills 2. Common emotional responses 3. Surveillance for common illness 4. Behavioral stress reduction techniques

Answer: 3 Explanation: 3. Basic safety monitoring and status reporting of a patient in crisis involves surveillance for common illness and suicide prevention. Stress reduction techniques are components of basic coping skills, and are a separate topic than from monitoring and status reporting. Common emotional responses would not be addressed in a session on basic safety monitoring and status reporting.

The nurse is assessing a child with depression. What is the best approach the nurse will use when assessing the child's socialization? 1. "How many friends do you have at school?" 2. "So you spend a lot of time with your friends?" 3. "Tell me about the friends you enjoy being with." 4. "You seem like a person who would have a lot of friends."

Answer: 3 Explanation: 3. By saying "Tell me about the friends you enjoy being with," the nurse is using therapeutic communication and encouraging the patient to talk about a positive aspect of life. The question "How many friends do you have at school?" can be perceived as probing and intrusive, which is nontherapeutic. Also, this type of question is close-ended, limiting the amount of detail the patient can provide. "So you spend a lot of time with your friends?" is also a close-ended question, not allowing the patient to elaborate on the answer. "You seem like a person who would have a lot of friends," is a judgmental observation that may also be viewed as a stereotypical comment.

A patient tells the mental health nurse that he is unable to get his life back together since the death of his spouse two years ago and that he feels the loss as strongly as he did the day his spouse died. What does the nurse suspect the patient is experiencing? 1. Delayed grief 2. Anticipatory grief 3. Complicated grief 4. Disenfranchised grief

Answer: 3 Explanation: 3. Complicated grief may be suspected when the intensity of suffering does not diminish over time, the patient does not resume previous roles, or the grief seems out of proportion to the loss. With delayed grief, the individual seems to feel no grief for a period of weeks, months, or even years. In anticipatory grief, an individual expects the loss before it occurs. Disenfranchised grief occurs when individuals hide grief following a loss to which some sort of stigma is, or may be, attached.

The nurse preceptor is giving a seminar about recognition and assessment of coping mechanisms found in older adult patients in crisis to a group of novice nurse. Which statement by the novice nurse indicates that the teaching has been effective? 1. "Older adult patients generally do not have well-established coping mechanisms." 2. "Older adult patients generally use physiological coping due to their advanced age." 3. "Older adult patients in crisis are more likely to suffer from a lack of social support." 4. "Older adult patients in crisis are more likely to suffer from a lack of belief-based coping."

Answer: 3 Explanation: 3. Crisis coping mechanisms vary across the life span. Older adults are more likely to suffer from a lack of social supports due to a variety of factors such as relocation and outliving some close family members and friends. Older adults generally have well-established coping mechanisms based on a life of experiences. Older adults generally do not use physiological coping as much as younger adults due physiological changes associated with aging. The older adult is more likely to use belief-based coping during crisis.

The nurse observes an 8-year-old child regressing to behavior that is characteristic of a toddler when faced with new situations. The child has been in several foster care families over the past three years. Which intervention is most appropriate for this child? 1. Providing for unmet needs. 2. Ignoring the regressive behavior. 3. Providing consistency and continuity of caregivers. 4. Ignoring the negative behavior and reinforcing the positive behavior.

Answer: 3 Explanation: 3. Defense mechanisms commonly employed by children are repression, reaction formation, and projection. The child comes to deal with the world through these distorted views in an attempt to defend against painful unconscious issues. Providing the child with consistency and continuity of caregivers will minimize situations that stimulate regression. Ignoring inappropriate or regressive behaviors and reinforcing positive behaviors will be insufficient to help this child return to age-appropriate behaviors. The child's greatest unmet need is related to consistency of caregivers.

A nurse educator is teaching a group of staff nurses on environmental risk factors that may lead to violence in the psychiatric setting. Which response by the staff nurse demonstrates that teaching has been effective? 1. "I will maintain the established patient routines." 2. "I will carefully manage patient transitions of care." 3. "I will allow visitors in the patient's room as permitted." 4. "I will assist the patient to maintain self-care."

Answer: 3 Explanation: 3. Environmental risk factors in the psychiatric setting include restrictions that infringe on individual freedoms, such as restricting visitors, locking doors, and taking away belongings (such as razors, electrical items, belts, and personal communication devices) to maintain safety. The other choices are appropriate nursing interventions; however, these pertain to unit-based routines and processes, not environmental risk factors.

A patient suffering from dissociative identity disorder complains of intrusive thoughts. The anticipates an order for which medication? 1. Insulin 2. Epinephrine 3. Beta-blocker 4. Benzodiazepine

Answer: 3 Explanation: 3. Guidelines by the International Society for the Study of Trauma and Dissociation suggest that medications used in the treatment of patients with dissociative disorders should target the symptoms that are disturbing to the patient. SSRIs and beta-blockers are used to treat hyperarousal and intrusive thoughts, depressive symptoms, obsessive-compulsive thoughts and behaviors, and sleep disturbances. Benzodiazepines should not be used as they increase the risk of further dissociation; epinephrine is a catecholamine, and insulin is a hormone.

) A community nurse is concerned about risky adolescent behavior online. What might be an appropriate subject for a parent workshop to help address this issue? 1. How to use social media 2. How to keep children off the Internet 3. Strategies that promote Internet safety 4. Techniques for getting access to children's Internet communications

Answer: 3 Explanation: 3. Helping parents and children navigate the Internet with safety and privacy is an important family intervention that will protect the entire family from potential harm. Knowing how to use social media does not provide protection from possible threatening behavior, victimization, and sexual abuse. Keeping children off the Internet does not provide them with the tools to safely navigate it. Getting access to Internet communications does not teach children how to use the Internet safely.

The community health nurse is teaching a class to a group of college women at the local community college. The nurse's teaching is focused on the risk factors of interpersonal violence (IPV) and rape. Which statement by the college student indicates that the nurse's teaching has been effective? 1. "Interpersonal violence is typically committed by men only." 2. "Interpersonal violence is typically committed by young individuals." 3. "Interpersonal violence is usually related to dynamics of power and control." 4. "Interpersonal violence is usually related to the concepts of self-esteem and self-worth."

Answer: 3 Explanation: 3. IPV, or domestic violence, involves aggressive behavior of many types between individuals in an intimate or dating relationship. IPV is usually related to dynamics of power and control, not self-esteem and self-worth. While IPV most often refers to violence toward women by men; however, women may engage in an equal amount of violence toward men, although the results of male partner violence are stronger and more severe. IPV may occur at any age.

The nurse is caring for a victim of interpersonal violence who tells the nurse, "I am really scared about going back to my apartment. I am afraid my boyfriend might try to hurt me again." What is the nurse's best response? 1. Help the patient contact the police. 2. Help the patient develop a plan of safety. 3. Help the patient find a temporary, safe shelter. 4. Help the patient file a domestic violence report.

Answer: 3 Explanation: 3. If the patient is ready to leave, the nurse must help ensure the patient's safety by helping the patient find temporary, safe shelter. For patients who need time or are not ready to leave an abusive situation, it is important to help them develop plans for their safety (and for the safety of their family, if the victim has children or other dependents) and provide support until they are able to resolve this problem. The nurse can support the patient in contacting the police and filing a domestic violence report, but doing so will not ensure the patient's immediate safety, which is the nurse's priority for care.

The novice nurse asks another nurse about differentiating delirium from dementia. The experienced nurse will respond that which change in mental status is consistently seen in patients with delirium and is not seen in patients with dementia? 1. Apraxia 2. Disorientation to self 3. Altered level of consciousness 4. Impaired short-term memory

Answer: 3 Explanation: 3. Individuals with delirium have fluctuating consciousness, but individuals with dementia are as attentive as they can be and do not experience altered consciousness until terminal stages. Impaired short-term memory is consistently seen in dementia. Apraxia is the loss of purposeful movement without loss of muscle power or coordination and is not seen in delirium. Disorientation to self is seen in amnesiac disorders, not delirium.

What does the nurse recognize as a risk factor for the development of delirium in older adults? 1. A lack of rigorous exercise that leads to decreased cerebral blood flow 2. Decreased social interaction that leads to profound isolation and psychosis 3. Administration of multiple medications that may cause medication interactions or toxicity 4. Age-related cognitive changes that make older adult patients more susceptible to changes in mental status

Answer: 3 Explanation: 3. Multiple medications may cause medication interactions or toxicity that may result in delirium. While the older adult patient is at higher risk for delirium, delirium is not caused by age-related cognitive changes. A lack of rigorous exercise will not promote delirium. Decreased social interaction can exacerbate delirium, but does not cause the condition.

The nurse is caring for a patient with dissociative identity disorder who has been admitted to the hospital for dehydration. Which question is the priority for including in the assessment? 1. "Do you remember what you were doing today?" 2. "Do you look in the mirror and not recognize yourself?" 3. "Do you ever think about harming yourself?" 4. "Do you find new things among your belongings that you don't recall obtaining?"

Answer: 3 Explanation: 3. Patients with dissociative disorders have a high risk for suicide. It is important to ask these patients direct questions about risk for suicide and self-harm. The other questions may be appropriate, but they are not the priority. Assessing for safety always takes priority.

The nurse knows that which modality is the best for patients with dissociative disorders? 1. Group therapy 2. Support groups 3. Individual psychotherapy 4. Dialectical behavior therapy

Answer: 3 Explanation: 3. Patients with dissociative disorders require long-term therapy. The best modality for this type patient is individual psychotherapy. Group therapy, support groups, and dialectical behavior therapy are not typically recommended for patients with dissociative disorders.

The nurse is caring for a patient with somatic symptom disorder. What information is most important for the nurse to include in the report to the staff on the next shift? 1. The trigger for the patient's worries 2. The original source of the patient's anxiety 3. The amount of time the patient talked about physical complaints 4. The patient's use of abdominal breathing at the first sign of anxiety

Answer: 3 Explanation: 3. Patients with somatic symptom disorder exhibit excessive focus on their physical symptoms. It is essential the staff on the next shift know how much time the patient talks about physical complaints in order to evaluate whether the patient meets the goal of decreasing that time spent on talking about the physical complaints. While the other information may be helpful to other staff members, it is not as important as how much time the patient has spent focusing on physical complaints.

The nurse is performing a mental status examination when caring for a patient with a neurocognitive disorder (NCD). The patient's spouse asks why a mental status examination is necessary. How will the nurse respond? 1. "The mental status exam is the only way to assess the cognitive decline of a patient with early stage Alzheimer disease." 2. "The mental status exam is used to assess depression in a patient with early stage Alzheimer disease." 3. "The mental status exam will reveal slow and progressive cognitive decline of a patient with early stage Alzheimer disease." 4. "The status exam will reveal rapid and dramatic changes in cognition of a patient with early stage Alzheimer disease."

Answer: 3 Explanation: 3. Psychological assessment of the individual with NCDs focuses on cognitive changes revealed through the mental status examination, as well as the resulting behavioral manifestations. In the patient with dementia, a mental status examination may not initially reveal a cognitive deficit, but will show a slow but progressive change if administered at given intervals over time. The mental status examination is not the only way to assess the cognitive decline of a patient with early stage Alzheimer disease; rather, the patient's family is often who notices the cognitive decline first. The nurse will often use the family member's assessment of the patient's cognition, and use this information to further assess the patient's mental state. Rapid and dramatic changes to a mental status exam, often indicates delirium, not dementia. Mental status examinations are not used to assess for depression.

What other experience might a nurse have had that would contribute to the intensity of grief when a patient dies? 1. Job changes 2. Individual counseling 3. The recent loss of a family member 4. Attending the patient's memorial service

Answer: 3 Explanation: 3. Recent personal experiences of death can increase the nurse's emotional response to the death of a patient. Job changes are not a powerful contributing factor to the intensity of suffering. Individual counseling can help the nurse consider her feelings. Attending memorial services and reflecting on memories may be helpful.

) The advanced practice nurse (APRN) is caring for a patient who recently relocated from another city. The patient is reporting depressive symptoms and no previous history of depression. Which therapy will the APRN be most likely to discuss with the patient? 1. Pharmacotherapy 2. Psychological first aid 3. Cognitive-behavioral therapy 4. Critical incident stress debriefing

Answer: 3 Explanation: 3. Short-term cognitive-behavioral therapy is considered the first-line treatment for individuals experiencing mood symptoms secondary to crisis. Pharmacotherapy, psychological first aid, and critical incident stress debriefing are therapies that may be used in the collaborative care of a patient experiencing crisis; however, these are not considered to be the first-line treatments for the patient experiencing mood symptoms secondary to crisis.

The community health nurse is teaching a group of adults about crisis experienced by various populations. Which statement by one of the group members indicates that the nurse's teaching has been effective? 1. "A good example of an adventitious crisis is a complicated divorce." 2. "I will be aware that maturational crisis may occur more frequently among my older adult patients." 3. "Patients with chronic illness are at greater risk for situational crisis than individuals without chronic illness." 4. "Adventitious crisis may occur in patients who have miscarried during pregnancy or have delivered a preterm infant."

Answer: 3 Explanation: 3. Situational crises develop in response to sudden, unexpected traumatic life events. Situational crises often are beyond the established coping capabilities of the individuals experiencing them. Situational crises can arise from many kinds of precipitants, including medical (acute onset injury or new chronic illness diagnosis), psychosocial (divorce, legal problems, financial problems), and cultural (immigration). Patients with chronic illness are at greater risk for situational crisis than individuals without chronic illness. A complicated divorce is more likely to be a situational crisis than an adventitious crisis. Adventitious crises arise from traumatic events that are well beyond the expected scope of normal human experience, such as violent crime, natural disasters, war, and terrorism. Maturational crisis occurs more frequently in adolescents and young adults than in the older adult population. Patients who have miscarried during pregnancy or have delivered a preterm infant are at greater risk for a maturational crisis or situational crisis, not an adventitious crisis.

The nurse is caring for a patient with Alzheimer disease. The nurse notes that the health care provider documented that the patient has neurocognitive disorder instead of documenting dementia. Why would the health care provider document in this manner? 1. The word dementia is outdated and no longer used. 2. The word dementia does not describe the patient's condition. 3. The word dementia may increase stigma regarding the patient's condition. 4. The word dementia may be confused with delirium.

Answer: 3 Explanation: 3. Some clinicians consider the term dementia as stigmatizing and favor the term neurocognitive disorder. The term dementia is not outdated. The health care provider would not avoid using the word dementia in documentation out of concern other clinicians might confuse the term with delirium. The term dementia is appropriate for use when describing Alzheimer disease.

A nurse is describing the multifactorial perspective of mental health and illness to the parents of a child recently diagnosed with autism spectrum disorder. Which statement would the nurse utilize when describing this approach? 1. Exposure to drugs and alcohol has been associated with psychiatric disorders. 2. Early psychological trauma may create deficits or abnormalities in brain structure. 3. The child's genetically determined attributes and life experiences interact to influence mental health outcomes. 4. The feedback mechanism appears dysfunctional, creating neurotoxic effects on brain development and function.

Answer: 3 Explanation: 3. The best explanation of the multifactorial nature of psychiatric disorders is that genetically determined attributes and life experiences interact to influence mental health outcomes. Discussing the association of exposure to drugs and alcohol to psychiatric disorders partially explains complications occurring during the perinatal period as a cause of some mental illnesses. Discussing the effects of early psychological trauma on brain structure partially explains nervous system responsiveness. Discussing feedback mechanism dysfunction would provide a partial explanation of neuroendocrine reactivity.

The psychiatric nurse is discussing indicators of conduct disorders in children with a group of student nurses. The nurse will be sure to discuss which behavior that children with conduct disorders find challenging? 1. Seeking out peers 2. Eating a balanced diet 3. Following rules and norms of behavior 4. Interpreting internal stimuli or external cues

Answer: 3 Explanation: 3. The central feature of a conduct disorder is repetitive and persistent behavior that violates the basic rights of others or major age-appropriate societal norms or rules. Behaviors that show aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of parental or school rules are indicators of a possible conduct disorder. The inability to eat a balanced diet is not an indicator of an emotionally disturbed child. Children with a conduct disorder tend to find peers with similar issues. Difficulty interpreting internal stimuli or external cues is not related to conduct disorders.

The nurse is preparing patient education for parents of children who have experienced trauma. What will the nurse explain regarding how the incorporation of yoga in the treatment plan might help a childhood trauma victim? 1. It can improve problem solving skills. 2. Yoga practice supports an improved self-image. 3. It may help trauma victims feel safe and grounded. 4. Yoga practice improves social skills and interactions.

Answer: 3 Explanation: 3. The effect of yoga may be activation of the parasympathetic nervous system, enhancing an individual's capacity to feel safe and grounded. Yoga practice is not associated with problem solving skills. There is no evidence of improved self-image with yoga practice. Yoga does not improve social skills or relationships.

A nurse is working with a 17-year-old girl with bulimia nervosa. What experience in the nurse's own life could interfere most with nurse's objectivity? 1. The nurse has a poor body image. 2. The nurse has a friend who was bulimic. 3. The nurse was bulimic as an adolescent. 4. The nurse has never had any personal experience of bulimia.

Answer: 3 Explanation: 3. The nurse must be careful to understand and mediate his or her own experiences as a child and as an adult; direct experience with a disorder such as bulimia can have a significant impact on the nurse's objectivity. A poor personal body image is important to acknowledge when treating someone with bulimia, but its impact is not as significant as having suffered from the disorder. Although knowing someone with bulimia can provide additional information about the condition, it is not likely to have a powerful impact on objectivity. Personal experience with a disorder is not a prerequisite to professional treatment of the problem.

The nurse is caring for a patient with Alzheimer disease who is no longer able to make or plan meals and who is having difficulty managing her personal finances. What stage of Alzheimer disease does the nurse suspect the patient has? 1. Preclinical 2. Mild cognitive impairment 3. Dementia 4. Asymptomatic

Answer: 3 Explanation: 3. The patient presents with dementia, which is the third stage Alzheimer disease At this stage, patients are unable to make or plan meals or the take care of the needed finances at home. Asymptomatic, or preclinical, refers to stage 1 of Alzheimer disease when symptoms are either absent or are so subtle that they go undetected. Mild cognitive impairment describes the severity of stage 2 Alzheimer disease.

The nurse is caring for a 75-year-old man with stage 3 Alzheimer disease. The patient's daughter tells the nurse that the family is concerned about his safety because he has fallen three times in the past year. What condition that is associated with Alzheimer disease does the nurse suspect the patient is experiencing? 1. Aphasia 2. Amnesia 3. Apraxia 4. Agnosia

Answer: 3 Explanation: 3. The patient's daughter is describing the presence of apraxia, which is the loss of purposeful movement in the absence of motor/sensory impairment. This condition leads to the patient falling more frequently. While aphasia, amnesia, and agnosia are symptoms Alzheimer disease, they represent alterations in cognitive or sensory, not motor, functioning.

The nurse is planning a presentation on crisis intervention to faculty and staff at a local high school. What information will the nurse want to include? Select all that apply. 1. How to identify colleagues who are approaching exhaustion 2. How to conduct a psychological debriefing 3. How to reinforce basic coping skills with students 4. How to recognize common cultural responses to crisis 5. How to encourage social connectivity among other faculty and staff

Answer: 3 Explanation: 3. When providing education to faculty and staff, the nurse will provide general education regarding crisis, including information related to the stages of the General Adaptation Syndrome, the importance of social connectivity, and basic coping skills. Individuals from different cultures may respond differently in times of crisis. Psychological debriefing should be conducted by a trained professional.

The nurse in a clinic is caring for a patient whom she suspects has a somatic symptom or related disorder. Which risk factors will the nurse include in the assessment? Select all that apply. 1. Female gender 2. High achieving 3. Lower socioeconomic status 4. Older age 5. Recently divorced

Answer: 3 Explanation: 3. Within the sociological domain, patients suffering from somatic symptoms and related disorders are generally female, older, and/or of lower socioeconomic status. Patients with somatic symptom disorders feel that no one understands the physical symptoms and therefore will not help. They are unable to take part in hobbies or interests with others, so they are more likely to experience frequent unemployment than be high achieving. Divorce itself is not a risk factor for a somatic symptom or related disorder.

A patient presents for an annual physical. As the nurse conducts the assessment, which statement will suggest the patient is experiencing workplace bullying? 1. "My manager has not given me a raise in over 10 years." 2. "My manager criticizes my work all the time, despite the fact that my annual performance review is always positive." 3. "My manager does not invite me to team meetings and I miss out on important information, affecting my annual performance review." 4. "My manager does not provide any positive feedback on my work at all and my annual performance review remains unchanged."

Answer: 3 Explanation: 3. Workplace bullying can be defined as deliberate, repeated mistreatment of a worker over time by another worker; it involves negative and aggressive behaviors such as harassment, social exclusion, or interference with job performance. The manager who does not invite the employee to team meetings, affecting the employee's annual review, is displaying workplace bullying. A manager who has not given a raise is not displaying workplace bullying. Managers who criticize work and who do not give positive feedback are not necessarily engaging in workplace bullying if the employee's annual performance review has either been positive or unchanged.

A nurse is researching the trends of maturational crisis for a graduate-level research course. When considering risk factors for this type of crisis, which patients will the nurse determine are at greatest risk for developing a maturational crisis? Select all that apply. 1. Young child whose parent is murdered 2. Older adult whose spouse recently passed away 3. Young adult single parent of two young children 4. College student who is attending an out-of-state university 5. Exchange student whose family has been killed in a terrorist attack overseas

Answer: 3, 4

The nurse educator is providing education to the staff nurses regarding the use of seclusion in the psychiatric setting. The educator asks the nurses to describe patients who would best benefit from seclusion. Which statements by the nurses would indicate that teaching has been effective? Select all that apply. 1. "The patient who throws a book on the ground in frustration." 2. "The patient who is loud and disrupting the milieu of the unit." 3. "The patient who attempts to cut herself with an object found on the unit." 4. "The patient who hits another patient in the face during a therapy session." 5. "The patient who is confused and disoriented with altered thought processes."

Answer: 3, 4

A patient's husband is dying of cancer. Which statements by the nurse are appropriate? Select all that apply. 1. "He's going to a better place." 2. "Don't worry. Everything will be OK." 3. "Please let me know if I can help in any way." 4. "Would you like to talk about what's happening?" 5. "Do you have any questions about what is happening with your husband?"

Answer: 3, 4, 5

An advanced practice psychiatric nurse (APRN-PMH) is evaluating what the most effective intervention options might be for a child diagnosed with selective mutism. What are some options the nurse should consider? Select all that apply. 1. Hypnotherapy 2. Parenting education classes 3. Antidepressant medications 4. Brief-solution focused therapy 5. Cognitive-behavioral therapy (CBT)

Answer: 3, 5

The nurse is caring for a patient with suspected delirium. In addition to the sudden onset of symptoms, the nurse can expect to find alterations in which functions during the assessment? Select all that apply. 1. Abstract thinking 2. Concrete thinking 3. Memory 4. Concentration 5. Consciousness

Answer: 3, 5 Explanation: 3. Delirium results in alterations in memory and consciousness. An alteration in abstract thinking occurs with dementia, not delirium. An alteration in concrete thinking does not occur with delirium. 5. Delirium results in alterations in memory and consciousness. An alteration in abstract thinking occurs with dementia, not delirium. An alteration in concrete thinking does not occur with delirium.

A patient who is a senior in high school fails two classes and is unable to graduate. Which type of crisis is the patient likely experiencing? 1. Biological crisis 2. Situational crisis 3. Adventitious crisis 4. Maturational crisis

Answer: 4 Explanation: 4. A maturational crisis may occur when an individual has difficulty achieving a developmental task such as graduating from high school. Situational crises typically arise from sudden, unanticipated events or changes. The patient likely knew about the failing grades. Adventitious crises arise from traumatic events that are well beyond the expected scope of normal human experience, such as violent crime, natural disasters, war, and terrorism. Biological is a stage of wellness, not crisis.

The nurse is researching violence in the community as part of a community health assessment. Using the broken windows theory, which factor will the nurse research? 1. Level of finances of the community members 2. Level of parental guidance in the community members 3. Level of education in both the community members and the larger society 4. Level of engagement by both the community members and the larger society

Answer: 4 Explanation: 4. According to the broken windows theory, when a neighborhood or area is run down and appears to be lacking engagement or investment by both community members and larger society, there will be a disproportionate amount of violence and crime, and further disorder will occur. While the other answer choices may be important to assess in a community with increased violence, these are not the primary causative factors of violence according to the broken windows theory.

The nurse is caring for a patient with dementia due to Alzheimer disease. What is the nurse's best understanding of the etiology of this disease? 1. A presence of eosinophilic inclusion bodies in the cortex and brain stem results in impaired cognitive function. 2. An infectious form of a normally harmless type of protein, called a prion, interferes with neuronal health, leading to dementia. 3. Multiple vascular lesions occur in the cerebral cortex and subcortical structures, resulting from the decreased blood supply to the brain, lead to a decline in cognitive function. 4. A buildup of beta amyloid plaques and tangled strands of tau protein interferes with neuronal health, communication, and transport functions, leading to dementia.

Answer: 4 Explanation: 4. Alzheimer disease occurs when a buildup of beta amyloid plaques and tangled strands of tau protein interferes with neuronal health, communication, and transport functions, leading to dementia. Eosinophilic inclusion bodies, also known as Lewy bodies, are seen in Lewy body dementia. Vascular dementia occurs when multiple vascular lesions are present in the cerebral cortex and subcortical structures, resulting from the decreased blood supply to the brain.

A nurse is working with a patient and realizes that it is almost one year since the death of the patient's spouse. What should the nurse do? 1. Ignore it unless the patient mentions it. 2. Tell the patient to visit the spouse's grave that day. 3. Suggest that the patient make plans to go away that day. 4. Prepare the patient for a possible anniversary reaction and help the patient plan for it.

Answer: 4 Explanation: 4. Anniversaries of loss may trigger increased sadness and anxiety. Nurses can teach the patient and family to prepare for an anniversary so they can take an active part in coping with a difficult time. Ignoring the anniversary will not help the patient develop coping strategies. Patients should not be told what rituals or activities would be most helpful to them.

A nurse is interviewing a 76-year-old patient who lost her spouse of 51 years over a year ago. The patient describes herself as feeling intensely sad and hopeless all the time. What is an appropriate response for the nurse? 1. Assess the patient as experiencing normal grieving. 2. Decide that the patient is experiencing unresolved grief. 3. Determine that the patient is experiencing chronic sorrow. 4. Determine that further assessment for depression is needed.

Answer: 4 Explanation: 4. Based on the patient's feeling of hopelessness and the duration of intense grieving, the patient should be evaluated for depression. Normal grieving is not characterized by hopelessness. Unresolved grief occurs when individuals suppress or avoid grief. Chronic sorrow is a response to an ongoing source of grief.

The nurse is performing a crisis assessment on a patient who is experiencing crisis due to a recent divorce. Which statement made by the patient will alert the nurse that the patient is experiencing the exhaustion phase of crisis? 1. "I can't believe this is happening to me." 2. "I have called my mom to help me with the kids." 3. "I am tired from moving all of my belongings into a new house. " 4. "I just can't seem to cope anymore. I am not sure what I am going to do."

Answer: 4 Explanation: 4. Classifying the stage of adaptation displayed by the individual is a component of the initial crisis assessment. The General Adaptation Syndrome describes three basic stages through which most individuals progress during attempts to cope with significant stressors: alarm, resistance, and exhaustion. The statement, "I just can't seem to cope anymore. I am not sure what I am going to do" is characteristic of the exhaustion phase of crisis. Exhaustion occurs when coping resources are low or depleted. The statement, "I can't believe this is happening to me" best describes the alarm stage of crisis, which occurs during the initial reaction to a crisis. The statements "I have called my mom to help me with the kids" and "I am tired from moving all of my belongings into a new house" best describe the resistance stage of crisis when the individual mobilizes resources in an effort to attempt to resolve the stressor.

An 82-year-old man is admitted to a medical-surgical unit for diagnostic confirmation and management of suspected delirium. Which statement by the patient's daughter best supports the diagnosis? 1. "Dad has always been so independent. He's lived alone for years since my mom died." 2. "Dad just hasn't seemed to know what he's been doing lately. He has been very forgetful these last few months." 3. "Maybe it's just caused by aging. This usually happens by age 82." 4. "The changes in his behavior came on so quickly. I wasn't sure what was happening."

Answer: 4 Explanation: 4. Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. The fact that the patient has been independent has no bearing on his current symptoms.

What is the most appropriate initial nursing intervention, which promotes stress reduction and healthy coping in a patient who is diagnosed with a dissociative disorder? 1. Encourage the patient to increase contact with friends and family. 2. Disregard the patient's other personalities. 3. Help the patient create distance from family members who do not believe the patient is sick. 4. Determine patient's level of safety and encourage the patient to recognize triggers.

Answer: 4 Explanation: 4. Determining patients' level of safety and encouraging patients to recognize triggers are an important initial intervention to ensure safety and promote stress reduction and healthy coping. The nurse should not encourage the patient to increase contact with friends and family or assist the patient in distancing from family members until there is a clarification of the relationships and their role in the patient's life. Disregarding the patient's other personalities does not promote effective role performance and is not the correct answer.

The nurse is caring for a patient who has expressed a desire to commit suicide. Which statement by the nurse is most appropriate? 1. "Your problems will get better. Hurting yourself is not the answer." 2. "Your family and friends will be very upset at you if you hurt yourself." 3. "I am shocked that you would consider hurting yourself. You have so much to live for." 4. "I am here for you. I know you want to hurt yourself, but there are things we can do to help you."

Answer: 4 Explanation: 4. For a patient who is expressing thoughts of suicide, it is important for the nurse to offer self and instill hope. The statement, "I am here for you. I know you want to hurt yourself, but there are things we can do to help you," best demonstrates offering self and instilling hope. The nurse should not provide false reassurance by stating, "Your problems will get better. Hurting yourself is not the answer." The nurse is acting in a judgmental way when stating, "Your family and friends will be very upset at you if you hurt yourself," or "I am shocked that you would consider hurting yourself. You have so much to live for." These statements are not therapeutic and not beneficial to a patient who is experiencing suicidal thoughts.

A nurse is assessing a 54-year-old flood victim who reports having difficulty concentrating and functioning. What might the nurse ask to help evaluate whether or not the individual is suffering from depression? 1. "Do you feel anxious?" 2. "Do you have any sleep problems?" 3. "Do you have any appetite problems?" 4. "Did you feel this way before the flood?"

Answer: 4 Explanation: 4. If the patient is experiencing their symptoms in response to a particular event, that is the most significant factor in establishing a differential diagnosis of grief. Anxiety, sleep problems, and appetite disturbances may be present in both grief and depression.

A patient tells the nurse, "I have been waiting two hours to be discharged. What is the problem?" The patient is pacing the room and glaring at staff members. What is the nurse's best action to prevent patient aggression? 1. Call hospital security to be prepared if the patient becomes aggressive. 2. Ask the patient to remain seated and retrieve the patient's discharge paperwork. 3. Acknowledge the patient's feelings and leave the room in order to avoid confrontation. 4. Acknowledge the patient's feelings and determine the status of the patient's discharge paperwork.

Answer: 4 Explanation: 4. In most cases, aggressive behavior is a response to an unmet need, often combined with underlying anxiety and poor coping mechanisms. The patient is displaying cues to aggressive behavior by pacing the room and glaring at staff members. The nurse's best action is to acknowledge the patient's feelings and determine the status of the patient's discharge paperwork. This action will validate the patient's feelings and attempt to address the patient's unmet needs. Calling hospital security does not address the patient's needs, nor does asking the patient to remain seated without validating the patient's concerns. Acknowledging the patient's feelings is the correct intervention; however, the nurse should intervene early, not leave the patient alone in the room.

A 29-year-old patient is admitted with nausea and diarrhea. She has not eaten anything since she learned her dog was hit by a car three days ago. She complains of "a migraine." The patient has a flat affect and her family says she "has not shed a tear." The patient is exhibiting which personality trait? 1. Negative Affectivity 2. Hypochondriasis 3. Dysthymia 4. Alexithymia

Answer: 4 Explanation: 4. Individuals with somatic symptom and related disorders complain of biological disorders focusing on those complaints to the extent of risking functional impairment in other domains. An individual with alexithymia is unable to identify or define feelings into words. Alexithymia has been linked to PTSD and migraine headaches. Negative affectivity is an independent risk factor for having multiple somatic symptoms; hypochondriasis refers to illness anxiety disorder; and dysthymia is a chronic depression.

The nurse administers lithium carbonate (Lithobid) to a child with obsessive-compulsive disorder (OCD). Which therapeutic effect will the nurse anticipate? 1. Weight loss 2. Weight gain 3. Elevated mood 4. Decreased agitation

Answer: 4 Explanation: 4. Lithium carbonate (Lithobid) is a mood stabilizer appropriate for use with children. Its primary use in patients with obsessive-compulsive disorder (OCD) is for reducing agitation rather than for managing mania. Weight gain is a side effect, not a therapeutic effect, of lithium use. Elevated mood and weight loss are not therapeutic effects of lithium carbonate (Lithobid).

A 12-year-old with ADHD is experiencing insomnia. The nurse anticipates providing patient education for which therapy? 1. Fluoxetine (Prozac) 2. Atomoxetine (Strattera) 3. Amphetamine sulfate (Adderall) 4. Melatonin

Answer: 4 Explanation: 4. Melatonin, a naturally occurring hormone, is considered by some an effective therapy in the long term for the treatment of chronic insomnia in children with ADHD. Fluoxetine (Prozac) is an antidepressant with insomnia as a possible side effect. Atomoxetine (Strattera) is used in the treatment of ADHD and may result in increased insomnia. Amphetamine sulfate (Adderall) is a stimulant and is not used to treat insomnia.

The nurse is caring for a patient with severe dementia. What nursing intervention best promotes orientation to time and space? 1. Provide good lighting, especially on stairs. 2. Acknowledge the patient's feelings. 3. Break instructions into short time frames. 4. Cover mirrors to decrease fear.

Answer: 4 Explanation: 4. Patient orientation in time and space is important regardless of the severity of illness and may present differently at different times. Covering or removing mirrors to decrease fear allows the patient to orient him or herself to the space without fear. The additional answer choices are appropriate interventions for patients with dementia; however, these interventions do not promote orientation to time and space.

The nurse preceptor is caring for a patient in physical restraints who is aggressive and threatening the safety of the staff. The nurse preceptor discusses the implications and requirements of this procedure with a novice nurse. What statement made by the graduate nurse indicates that the nurse preceptor's teaching has been effective? 1. "It is acceptable for the nurse to monitor the patient in physical restraints every hour to ensure the patient's safety." 2. "It is acceptable to place the patient in physical restraints if pharmacological methods have been unsuccessful." 3. "It is acceptable for the health care provider to assess the patient in restraints within 24 hours of restraint application." 4. "It is acceptable for the nurse to turn and reposition the patient in physical restraints every 2 hours to ensure the patient's skin integrity."

Answer: 4 Explanation: 4. Physical restraints are used only as a last resort, after all interventions have been tried and have been unsuccessful. The nurse must turn and reposition the patient in physical restraints at least every 2 hours to ensure the patient's skin integrity. The patient who is in physical restraints must be monitored constantly, not every hour, to ensure the patient's safety. All other possible interventions, not just pharmacological, must be attempted prior to the use of physical restraints. Additional interventions may include therapeutic communication techniques. Once physical restraints have been applied, the health care provider must assess the patient in restraints within 1 hour of restraint application.

The nurse is planning on providing primary intervention education for patients at risk for suicide. Which role will the nurse most likely assume? 1. Teaching first responders the signs of increased risk for suicide 2. Teaching a group of parents about the signs of suicidal gestures 3. Teaching a patient about re-establishing a healthy sense of self 4. Teaching community members about resources available to prevent a suicide attempt

Answer: 4 Explanation: 4. Primary intervention is used to reduce the risk of suicide or suicide attempt. The goal is to prevent suicide by helping individuals to receive assistance before hopelessness occurs and the individual views death as the only alternative. Teaching first responders the signs of increased risk for suicide, as well as teaching a group of parents about the signs of suicidal gestures are examples of secondary interventions. Teaching a patient about re-establishing a healthy sense of self is a tertiary intervention.

The nurse is planning care for a patient who is suspected of being at risk for suicide. Which question would be most appropriate for the nurse to ask the patient when determining the presence of protective measures? 1. "Do you have any thoughts of suicide?" 2. "Do you have a history of trauma in your past?" 3. "What symptoms of depression are you experiencing?" 4. "Do you identify with a religious or spiritual group?"

Answer: 4 Explanation: 4. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. Both religion and spirituality are protective measures that help reduce suffering and promote hope. Asking the patient, "Do you identify with a religious or spiritual group?" will help the nurse identify protective measures. Asking the patient if he or she has any thoughts of suicide, has a history of trauma, or has symptoms of depression, are appropriate questions; however, these questions assesses the patient's risk for suicide and do not address protective measures.

The nurse is caring for a patient who is displaying hopelessness. The nurse wants to assess if the patient has any internal protective measures that could be used to assist the patient to overcome suicidal thoughts. Which question is most appropriate for this purpose? 1. "How well do you relate to others?" 2. "Do you request assistance when needed?" 3. "Do you have valued relationships with others?" 4. "How do you handle conflicts with others?"

Answer: 4 Explanation: 4. Protective measures are factors that can help the individual to feel hopeful and worthy enough to begin problem solving, even when he or she feels that there are no answers to the presenting problem. There are internal and external protective measures. Internal factors are related to the ability to problem solve, think through conflict, and handle disputes without violence. The question, "How do you handle conflicts with others?" best assesses the presence of internal protective measures. The ability to relate to others, connect to family, and to request assistance address external, not internal, protective measures.

After the death of a child, a patient is experiencing depression and anxiety. The nurse anticipates the need to provide patient education regarding which type of therapy? 1. Hypnosis 2. Desensitization 3. Benzodiazepines 4. Psychotherapy

Answer: 4 Explanation: 4. Psychotherapy has been found to be helpful in grieving patients who exhibit symptoms of clinical depression, especially when used in combination with antidepressants. Hypnosis is usually part of suggestion therapy or psychoanalysis and is not typically used in treating patients experiencing depression associated with grief. Desensitization is used to treat phobias. Benzodiazepines may be used for anxiety but may block the experience of grief.

A nurse is meeting with a 14-year-old girl who reveals that she frequently engages in cutting. Which thought of the nurse's would be most therapeutic? 1. She must be depressed. 2. She needs an immediate medication evaluation. 3. This is typical behavior adolescent behavior and not really a big problem. 4. I must make sure she is safe and then I think we will need to work on this patient developing new coping skills.

Answer: 4 Explanation: 4. Regardless of the trigger, nursing care of the self-injurious child or adolescent is to ensure safety first, and then to help the patient develop new skills for problem solving and managing difficult emotions and interpersonal conflicts. Adolescents who self-injure differ from those with depression. Medication is not necessarily indicated in self-injury. Adolescents who self-injure may evidence delinquent behavior, PTSD symptoms, substance and tobacco use, greater degrees of hopelessness, higher impulsivity, and suicidal ideation.

The nurse is caring for a patient who is morbidly obese and who has been diagnosed with somatic symptom disorder. The patient history reveals that the patient's mother suffered from alcohol use disorder. Which domain does the nurse recognize as the most useful in explaining the patient's condition? 1. Cultural domain 2. Spiritual domain 3. Biological domain 4. Psychological domain

Answer: 4 Explanation: 4. Research into the emotional responses of individuals in their relation to their physical state lies within the psychological domain. Early childhood distress is associated with adult obesity and other physical illnesses. In the cultural domain somatic concerns vary depending on the culture or the country. In the spiritual domain, individuals may seek meaning and/or solace in their symptoms, or they may feel spiritually and emotionally disengaged. In the biological domain body sensations become the individual's focus and concern.

The community health nurse is providing education about various community services that patients and family members can use to prevent suicide. Which statement made by the nurse best exemplifies secondary prevention resources? 1. "Here is a brochure that lists the signs of suicide." 2. "Let me tell you the various resources available for the prevention of suicide." 3. "The hospital has a support group for survivors of suicide that meets every Tuesday." 4. "Let me discuss with you the benefits of early intervention for the prevention of suicide."

Answer: 4 Explanation: 4. Secondary prevention resources focus on early intervention and treatment. Primary prevention resources focus on prevention and recognition. Providing the patient with a brochure or a list of resources available are primary prevention interventions. Tertiary prevention resources focus on problem solving and support systems, as well as on establishing a healthy sense of self and self-reflection. A support group for survivors of suicide is an example of a tertiary prevention resource.

A 7-year-old child recently experienced the death of the family's pet dog. The dog was the child's constant companion. What does the nurse understand the child is at risk for developing as a result of the pet's death? 1. Agoraphobia 2. Conduct disorder 3. Elimination disorder 4. Separation anxiety disorder

Answer: 4 Explanation: 4. Separation anxiety disorder involves a developmentally inappropriate and excessive anxiety over separation from home or from attachment figures and may appear after a stressful life event, such as the death of a pet. This child's dog may be viewed as an attachment figure, thus placing this child at risk for a separation anxiety disorder. Agoraphobia, the fear of being in public places, is not related to this situation. Risk factors for conduct disorder are related to difficulties with parent-child interactions. Children with elimination problems may have psychosocial risk factors. However, the child who experiences a significant family loss is at increased risk for separation anxiety disorder.

The nurse is caring for a patient who is experiencing a situational crisis. Which statement by the nurse best reflects the therapeutic communication necessary when caring for this patient? 1. "It's best to stay busy." 2. "It could have been worse." 3. "I know just how you feel." 4. "I am sorry this happened to you."

Answer: 4 Explanation: 4. Stating that the nurse is sorry for what the patient has experienced reflects empathy. Assessing the patient's current emotional state and coping mechanisms that have been effective in the past require open-ended questions and attentive listening. Stating that the nurse knows how the patient feels hinders this communication and takes the focus off the patient. Telling the patient to stay busy does not empower the patient to identify and adopt coping strategies. Telling the patient it could have been worse minimizes the patient's unique experience.

A 12-year-old patient, who was recently place in foster care after one year in a residential facility, reports recurring nightmares about a violent event in the residence. He also has some difficulty remembering and concentrating. The nurse suspects the patient may be developing which disorder? 1. Depression 2. Separation anxiety 3. Pediatric bipolar disorder (PBD) 4. Posttraumatic stress disorder (PTSD)

Answer: 4 Explanation: 4. Symptoms of PTSD include recurring, distressing dreams related to the event as well as memory impairment, impaired information processing, and difficulty concentrating. Children who are depressed typically cannot communicate their sadness with words, as in verbal reports of troubling dreams, but instead communicate to others with their withdrawn, sad, and/or irritable mood states. Separation anxiety occurs when a child exhibits great fear and distress when separated from parents or home. Pediatric bipolar disorder (PBD) is characterized by significant mood disturbances, including elated or irritable mood.

The nurse is caring for a patient who tells the nurse, "I attempted suicide last year but I feel like I am doing better now." On what will the nurse focus during patient education? 1. Emphasizing that the patient seek and use resources to prevent a suicide attempt 2. Encouraging the patient to call family members for support when having feelings of suicide 3. Developing a pamphlet of information that the patient will use to increase knowledge on suicide prevention 4. Encouraging the patient attend a support group with other individuals who have attempted suicide

Answer: 4 Explanation: 4. Tertiary intervention addresses the needs of individuals who have survived a suicide attempt and are on the road to recovery. Encouraging the patient attend a support group with other individuals who have attempted suicide is an example of a tertiary intervention. Encouraging the use of resources and the use of family support are secondary interventions. Developing a pamphlet is a primary level intervention.

The nurse is caring for four patients at risk for suicide. Which patient would benefit most from tertiary prevention of suicide? 1. The patient who presents to the primary care clinic for an annual wellness exam 2. The patient who presents to the local urgent care expressing hopelessness 3. The patient who presents to the emergency department after surviving a suicide attempt 4. The patient who presents to the outpatient clinic who has survived a previous suicide attempt

Answer: 4 Explanation: 4. Tertiary intervention involves interventions after the person has survived a suicidal gesture and is on the road to recovery. The goal is to assist the individual in problem solving and connecting with a support system to prevent a recurrence of suicidal thoughts and enhance day-to-day functioning. The patient who is having an annual well exam will best benefit from primary intervention. Secondary intervention is best for patients who seek resources with symptoms of hopelessness or after a suicide attempt.

A group of nurses were discussing psychological issues related to childhood abuse. Which statement indicates their understanding of these issues? 1. "It doesn't matter where the abuse occurs." 2. "Children under 10 can't be diagnosed with PTSD." 3. "Most abused children develop long-term psychological problems." 4. "The frequency and number of abusive events influences the severity of the psychological distress."

Answer: 4 Explanation: 4. The frequency and number of abusive events influences the severity of psychological distress. If the home environment is the source of maltreatment, trauma can result in more significant consequences due to the lack of supports. Children under 10 can have PTSD. Most children do not develop long-term problems secondary to abuse, but some continue to respond to their environment in ways that have a long-lasting impact on their functioning.

A patient who has just lost all her family photos in a flood asks the nurse why she seems to be suffering as much as her neighbor, who lost her entire house and all her possessions. What can the nurse say to help explain what can be the most important factor in determining the intensity of a loss? 1. The age of the person is the most important factor in determining the intensity of the loss. 2. The gender of the person is the most important factor in determining the intensity of the loss. 3. The value of the loss is the most important factor in determining the intensity of a person's loss. 4. The meaning of the loss is the most important factor in determining the intensity of the response to loss.

Answer: 4 Explanation: 4. The intensity of reaction to loss varies according to the meaning of the loss to the individual. Although the age and gender may be associated factors determining the intensity of a loss, the meaning of the loss is the most significant factor. The value of the loss is a contributing but less significant factor to the intensity of loss.

At an annual employee health fair, the nurse educator is presenting information to staff regarding negative emotions that may occur when caring for patients who are anxious, angry, and aggressive. Which staff member statement indicates that the teaching has been effective? 1. "Self-awareness prevents the nurse's negative emotions." 2. "Self-awareness allows the nurse to express sympathy for the patient." 3. "Intense negative emotions guide the nurse to plan appropriate interventions." 4. "Intense negative emotions interfere with the nurse's assessment and judgment."

Answer: 4 Explanation: 4. The nurse may develop intense negative emotions when caring for patients who are anxious, angry, and aggressive. It is vital that the nurse use self-reflection in order to promote the nurse's own health and well-being. Intense negative emotions interfere with the nurse's ability to perform an objective assessment, and interfere with the nurse's judgment. Self-awareness does not prevent negative emotions, but is a technique used to manage these emotions. Self-awareness allows the nurse to express empathy, not sympathy for the patient. Intense negative emotions interfere with the nurse's ability to plan appropriate intervention.

The nurse preceptor is caring for a patient who has a history of aggressive behavior. The novice nurse asks, "Why is the patient taking a cardiac medication if he does not have a heart condition?" What is the preceptor's best response? 1. "Calcium channel blockers increase dopamine levels, decreasing the risk of violence." 2. "Calcium channel blockers decrease dopamine levels, decreasing the risk of violence." 3. "Beta-adrenergic agonists decrease norepinephrine levels, decreasing the risk of violence." 4. "Beta-adrenergic antagonists decrease norepinephrine levels, decreasing the risk of violence."

Answer: 4 Explanation: 4. The nurse must be aware of the neurobiology associated with aggression. Beta-adrenergic antagonists are used in the collaborative treatment of aggression as well as to treat cardiac conditions. Beta-adrenergic antagonists decrease norepinephrine levels, decreasing the risk of violence. Beta-adrenergic agonists and calcium channel blockers are not used in the collaborative treatment of aggressive behavior.

What is the best action by the nurse to intervene effectively with patients who have been diagnosed with somatic symptom disorder? 1. Address patient's anxiety at a later time. 2. Help the patient express a decreased degree of comfort regarding physical symptoms. 3. Encourage the patient's expression of feelings symbolically through physical symptoms. 4. Recognize and understand the patient conceptualizes the symptoms to be physical in nature.

Answer: 4 Explanation: 4. The nurse should recognize and understand the patient conceptualizes the symptoms to be physical in nature. The nurse should not encourage expression of feelings symbolically through physical symptoms. Patient anxiety should be addressed immediately, not at a later time. The patient should express an increased, not decreased, degree of comfort regarding physical symptoms.

The nurse is caring for a patient who appears anxious and is pacing the room and clenching his fists. What action best demonstrates the core concept of effective intervention for this patient? 1. Administering a medication to the patient 2. Deciding to promptly isolate the patient from others 3. Assessing the patient's perception of his level of anxiety 4. Demonstrating therapeutic communication with the patient

Answer: 4 Explanation: 4. The patient in the scenario is displaying escalating anxiety, which may lead to aggression and violence. Interventions for a patient who is displaying anxiety, frustration, anger, and aggression are based on the core principle of therapeutic communication. Pharmacological therapy may be used in the treatment of this patient; however, this is not the core concept of effective intervention for this patient. While prompt decision-making is appropriate for this patient, isolating the patient is not and does not represent the core concept of effective intervention for this patient. While it may be appropriate to assess the patient's perception of his level of anxiety, this does not represent the core concept of effective intervention for this patient.

The nurse is caring for a patient in an outpatient clinic who has selected and obtained lethal measures to follow through with suicide completion. What nursing intervention is most appropriate for this patient? 1. Encourage the patient to attend psychotherapy. 2. Encourage coping skills, such as stress reduction. 3. Facilitate assessment in the emergency department to determine the appropriate level of care. 4. Arrange for transportation to the emergency department and plan for admission to the behavioral health unit.

Answer: 4 Explanation: 4. The patient who has selected and obtained lethal measures to follow through with suicide completion is in Stage V of the Stage of Severity for Suicide Risk. This is the most severe stage, at which the nurse needs to intervene to ensure the patient's safety. This will include transportation to the emergency department for evaluation and planning for the patient to be admitted to the behavioral health unit. While the other answer choices are appropriate interventions for a patient displaying suicidal thoughts or actions, these interventions are only appropriate for those individuals with less severity of suicide risk, such as in stages I through IV.

The nurse educator is teaching a review course to the staff nurses on the role of neurobiology in aggressive behavior. The nurse educator asks a staff nurse to identify the patient on the unit who is most at risk for aggression, based on neurobiology. Which statement by the staff nurse indicates that the teaching has been effective? 1. "A 73-year-old female with a history of chronic neuropathy." 2. "A 42-year-old female with a history of multiple sclerosis (MS)." 3. "A 55-year-old male with a history of chronic migraine headaches." 4. "A 32-year-old male with a history of a traumatic brain injury (TBI)."

Answer: 4 Explanation: 4. The patient with a history of a traumatic brain injury (TBI) is at greatest risk for aggressive behavior. In addition, the patient's younger age and male gender increases the risk for aggression. Chronic neuropathy, multiple sclerosis (MS), and chronic migraine headaches are not associated with an increased risk of aggression.

A nurse asks a patient in a shelter for hurricane victims if she can be of help. The patient says, "I don't need your help." Using therapeutic communication, how should the nurse respond? 1. Move away from the patient. 2. Call the nursing supervisor. 3. Tell the patient that anger won't help her situation. 4. Tell the patient that anger is understandable in her situation.

Answer: 4 Explanation: 4. The therapeutic response to a patient's statement of irritability and rage is validate the patient's experience. Leaving or calling the supervisor does not provide a therapeutic interaction. Judgment about the patient's anger is an obstacle to therapeutic engagement.

A patient who lost a child in an auto accident tells the nurse, "God has abandoned me." What is an appropriate statement for the nurse to make? 1. "I will go and get a clergyman to help you." 2. "God has nothing to do with what happened to you." 3. "You need to strengthen your faith if you want to be able to survives this tragedy." 4. "Tell me more about what your faith means to you and, if you wish, I will get a clergyman to talk to you more about this tragedy."

Answer: 4 Explanation: 4. Therapeutic communication with patients experiencing spiritual confusion would include encouraging patients to explore their beliefs and find meaning in them, as well as offer the option for additional discussion with a clergyman. Leaving the patient to get a clergyman avoids the patient's need and does not demonstrate therapeutic communication. Imposing one's own beliefs or expressing judgments blocks further communication.

The nurse educator is presenting a review course on workplace safety and prevention of aggression. The nurse discusses the various types of workplace aggression. Which action will the nurse manager recommend for nurses to take to prevent type I aggression while at work? 1. Recognize escalating anxiety in visitors and family members of patients. 2. Report to the charge nurse when a health care provider gets angry at the nurse. 3. Report to the charge nurse any threats that a colleague or peer makes to the nurse. 4. Have a security guard escort the nurse outside if it is dark when the nurse leaves.

Answer: 4 Explanation: 4. Type I violence occurs when criminal intent or activity results in violence. In this type of violence, the perpetrator has no known relationship with the victim. Having a security guard escort the nurse to the nurse's vehicle will help to prevent this type of violence. Recognizing escalating anxiety in visitors and family members of patients is an appropriate intervention; however, this describes an intervention to prevent type II violence, not type I. Reporting threats from a peer or health care provider are appropriate interventions; however, these interventions best describe prevention against type III violence, not type I.

A patient lost his spouse three years ago. The nurse has been helping him work through his grief using Worden's stage theory of grieving. Which controversial stage might the nurse decide to eliminate? 1. Accept the reality of the loss. 2. Experience the pain of grief. 3. Adjust to an environment in which the deceased is missing. 4. Withdraw from the lost relationship and reinvest energy in new relationships.

Answer: 4 Explanation: 4. Worden's final stage of withdrawing from the lost relationship is controversial. Many believe is that it is unnecessary to detach in order to move on to new relationships, and the bereaved can maintain the attachment to a lost loved one in a number of ways. Accepting the reality of the loss, experiencing the pain of grief and adjusting to a world without the deceased person are tasks of grieving that must be completed or the person is at risk for future problems with adjustment.

The nurse is caring for a patient with a previous history of suicide attempt. The patient has been participating in the treatment plan, and while not actively suicidal, continues to express feelings of hopelessness. Which statements by the nurse would best promote hope for this patient? Select all that apply. 1. "Tell me about the struggles in your life." 2. "How are you trying to solve some of your problems?" 3. "Have you ever felt like you wanted to hurt yourself?" 4. "Are you getting any regular exercise?" 5. "You are doing a great job by participating in the ordered therapy."

Answer: 4, 5

The nurse is working with the parent of a child with a disability; the child requires ongoing support and intervention. The parent reveals struggling with anger and sadness that has not decreased in intensity since the child was born several years ago. The nurse understands that the parent is likely to be suffering from which type of grief or sorrow? A. chronic B. Ambiguous C. Anticipatory D. Disenfranchised

Correct Answers: a Rationale: Chronic sorrow is a type of grief that is ongoing and does not decrease in intensity over time. It can lead to hopelessness and depression and requires supportive intervention. Ambiguous grief occurs when the loss is uncertain, such as in the case of a missing loved one. Anticipatory grief occurs when an individual expects a future loss. Disenfranchised grief occurs when a loss is not recognized or socially supported.

The nurse is providing teaching to the parents of a child who has just experienced a traumatic event. The parents note that the child denies that anything is wrong and spends lots of time engaged in imaginative play. Which response is most appropriate? A. "your child is demonstrating a developmentally and psychologically typical response." B. "Denial is always a maladaptive response to stress that should be challenged right away." C. "there may be an issue with trust because children usually look to adults for guidance." D. "children are much more resilient that adults and traumatic events do not have the same degree of impact on them.'

Correct Answers: a Rationale: Denial in the early or alarm stage reaction to trauma is normal and can be adaptive response to a situation or experience that is too difficult to confront immediately. Children often rely on imaginative pathways to respond to crisis. There is not enough information and the stages of adaptation have not progressed enough to determine that there is an issue with trust. Although behavioral and emotional responses to crisis events differ, they are equally impacted and require the same level of support and intervention as adults.

The nurse is applying techniques of therapuetic communication with the significant other of a patient who has died. The patient is angry and asks the nurse to leave the room, stating, "If you people knew what you were doing, this never would have happened." Which type nursing responses is most appropriate? A. acceptance B. Information C. Meaning making D. reality orientation

Correct Answers: a Rationale: It is most important for the nurse to convey acceptance of the patient's anger and rage, which may be a defensive reaction to a recent loss. Providing information and using reality orientation or meaning making are unlikely to be useful as the individual struggles with overwhelming emotions associated with the acute grief reaction.

The nurse is completing an assessment of a patient being admitted to the inpatient mental health unit. Which initial assessment is most useful for identifying the risk that the patient will become violent or assaultive? A. level of anxiety B. Reality orientation C. Past episodes of violence D. history of incarceration

Correct Answers: c Rationale: Knowledge of the patient's history of violence is essential for predicting further violent episodes as well as formulating interventions to prevent them. Anxiety and impaired reality orientation are factors that can lead to aggression, but it is most important to identify the patient's tendency to respond with violent or out-of-control behavior. Many individuals with mental illness have a history of incarceration due to lack of appropriate services. Incarceration itself does not indicate that the patient is predisposed to violent behavior.

The nurse is caring for a patient with a dissociative disorder. The patient reports having been a victim of abuse while in the fourth grade. The patient states she is unable to remember any details of the event or anything else occurring and still cannot apply simple mathematical concepts that may have been introduced at this time. The nurse recognizes that the patient is experiencing which type of amnesia? A. Localized B. Selective C. Generalized D. Depersonalized

Correct Answers: a Rationale: Localized amnesia refers to the inability to recall specific events during a precise period of time. Individuals with this type of amnesia also do not recall the memories surrounding the occurrence of the event - in this case, learning mathematical concepts introduced at this time. Selective amnesia is characterized by the ability to recall some, but not all, of the events occurring during a specific time. Generalized amnesia represents a complete loss of memory of one's life history. Depersonalization relates to a feeling of being detached from one's self. This symptom is separate from amnesia and occurs in derealization/depersonalization disorder.

The nurse is working with a child who has been bullied at school. The nurse understands that which variable has the greatest potential to negatively affect the quality of care the nurse provides? A. the nurse has a child who is being bullied at school. B. the nurse had a few experiences with bullying as a child. C. the nurse recently attended a conference that addressed bullying. D. the nurse has worked with a number of children affected by bullying.

Correct Answers: a Rationale: Nursing care of children and their families can pose unique opportunities and challenges for the nurse. Having a child who is being bullied is likely to trigger strong, unresolved emotional responses in the nurse and is an example of a situation that requires understanding and mediation of personal experiences both as a child and an adult. Although a lack of personal experience with bullying may be a factor in understanding the perspective of those involved, it is less likely to produce an emotional response that has the potential to interfere with therapeutic outcomes. Education and professional experience related to bullying is likely to positively, not negatively, impact the quality of care provided.

The nurse is caring for a patient with a dissociative disorder. Based on an understanding of the nature of the disorder, which of the following nursing diagnoses is priority? A. Risk of suicide B. Ineffective coping C. Posttrauma Response D. Disturbed body image

Correct Answers: a Rationale: Research demonstrates that approximately 70 percent of outpatient patients receiving treatment for dissociative disorders have attempted suicide. Even if patients deny a history of past suicide attempts or state that they are not suicidal, there may be amnesia associated with past suicide attempts and or another alter personality may be suicidal. While all of the other diagnoses may be applicable the priority relates to preservation of life.

The nurse is providing teaching to school personnel related to the need to recognize and respond to children with mental health needs. Which statement by school personnel requires follow up? A. "The presentation of mental illness in children is similar to that observed in adults." B. "Most mental health care for children and adolescents occurs in nontraditional settings." C. Mental health disorders affect as many as one in five children and adolescents in any given year." D. "It is easy for parents and teachers to fail to recognize symptoms of mental illness due to common misconceptions ."

Correct Answers: a Rationale: The presentation and treatment of mental illness in children differs from that of adults; it is a misconception that children and adolescents are simply smaller versions of adults. The nurse would ensure that this statement was followed up with accurate information. It is true that most treatment of mental health issues for children occurs in nontraditional settings, such as the primary care provider's office. Mental illness impacts about 15% to 20% of all children and adolescents in any given year, and frequently goes undetected because symptoms are not recognized or understood.

The nurse is addressing health promotion activities across wellness domains that may reduce the incidence of childhood psychopathology. Which areas of focus are most appropriate? Select all that apply. A. diet B. prenatal care C. stress reduction D. parenting support E. milieu management

Correct Answers: a, b, c, d Rationale: Diet and prenatal care address health promotion behaviors that can reduce psychopathology that results from biological insults impacting growth and development. Stress reduction and parenting support address psychological health. Milieu management is a therapeutic intervention most often employed in settings used to treat children and adolescents who have already exhibiting psychopathology.

The nurse is assessing risk factors for suicide. Which woulda let the nurse to increased risk? Select all that apply. A. family history of suicide B. strong belief in an after life C. unsecured weapons at home D. pregnancy or dependent children E presence of cardiovascular disease

Correct Answers: a, c, e Rationale: Among the risk factors for suicide are a family history of suicide, easy access to lethal means such as a firearm, and a major physical illness. Protective factors are those that can assist the individual to be hopeful and begin to solve problems. Religious affiliation is a source of support; belief in the afterlife is not necessarily a risk factor for suicide. Another protective factor is the presence of valued relationships and a responsibility for caring for others. Therefore, pregnancy and dependent children would be considered protective factors.

The pediatric nurse is working with children with a variety of emotional and neurodevelopment issues. Which disorders does the nurse recognize as indicative of maltreatment and/or a response to an overwhelming stressor? Select all that apply. A. anxiety disorder B. attachment disorder C. post traumatic stress disorder D. pervasive developmental disorder E. disinhibited social engagement disorder

Correct Answers: a, c, e Rationale: Attachment disorder, posttraumatic stress disorder and disinhibited social engagement disorder are all classified as trauma- or stressor-related disorders. Anxiety disorders have a strong genetic component and do not necessarily indicate the presence of mistreatment or trauma. Pervasive developmental disorder (now classified under the term autism spectrum disorder) has a neurobiological etiology and is not related to mistreatment or trauma.

The nurse is planning teaching sessions for patients newly diagnosed with dissociative disorders and for patients who are experiencing somatic symptom disorder. Which statements related to the etiology of the disorders are accurate? Select all that apply. A. Both types of disorders have been linked to traumatic experiences. B. There is a neurobiological basis for somatic symptom disorders only. C. The suffering and pain associated with both types of disorders is overstated. D. Research has demonstrated that dissociative disorders cannot be deliberately enacted. E. Frequently, a diagnosis of somatic symptom disorder is concurrent with a diagnosis of a medical illness.

Correct Answers: a, d, e Rationale: Both somatic symptom disorders and dissociated disorders are associated with trauma experiences in childhood, as evidenced by research. Neurobiological changes occur in both disorders and contribute to the manifestation of symptoms. Research has shown that dissociative disorders cannot be enacted or induced. It is not unusual for individuals with somatic symptom disorder to have also been diagnosed with a concurrent medical disorder. The pain and suffering experienced by individuals with these disorders is real.

The nurse is evaluating the progress of a patient who has suffered the loss of a pregnancy. Which finding would be most concerning? A. The patient is acting strong to avoid upsetting her spouse. B. The patient expresses feeling defective, worthless, and hopeless. C. The patient reports that waves of grief occur 1 month after the loss. D. The patient is weepy and unable to concentrate 1 week following the lost.

Correct Answers: b Rationale: Although grief is highly individual, self-destructive thoughts or feelings of worthlessness and hopelessness require evaluation for depression and safety. Many people try to act strong after a loss to avoid upsetting others and, while this can be a sign of dysfunctional grieving, it does not pose an immediate danger to the patient. Intermittent waves of grief and sadness and an inability to concentrate in the acute grief period are typical grief responses.

The nurse is planning care for the adolescent who has experienced the death of a parent. This nurse recognizes that which aspect of development may complicate the adolescent's grief response? A. An exaggerated sense of shame B. feelings of isolation from others C. Tendency to view the loss as a punishment D. Inability to appreciate the permanence of the loss

Correct Answers: b Rationale: During adolescence, individuals are struggling to achieve independence from parents and are increasingly oriented toward their peer group. The death of a parent can lead to the adolescent feeling different or isolated from peers, who are dealing with other issues. An exaggerated sense of shame may be related to the cause of death (such as suicide), but is not necessarily associated with this stage of development. The tendency to view death as a punishment and the inability to view the loss as permanent are associated with cognitive development in the younger child.

The nurse is applying principles of grief to build self-awareness of the impact of caring for patients and families experiencing loss. Which does the nurse recognize as having potential to be determined to patients and families? A. expressing feelings to co-workers B. providing uninterrupted care C. examining feelings related to loss D. participating in memorial services

Correct Answers: b Rationale: In order to be present and available for patients, nurses must take breaks and engage in self-care activities. Providing uninterrupted care may actually interfere with the nurse's ability to be present and emotionally available. Expressing feelings to coworkers, examining feelings related to loss, and participating in memorial services address normal grief reactions in the nurse and ultimately contribute the nurse's capacity to reduce suffering in others.

The nurse in an inpatient unit is caring for a patient who has attempted suicide. Which intervention is consistent with evidence-based practice? A. Decreasing monitoring after a patient has completed a written safety agreement B. Questioning the patient frequently and explicitly about intent to commit suicide C. Providing reassurance that things will get better if the patient holds on and gives it some time D. Gently reminding the patient that his behavior has caused pain and suffering

Correct Answers: b Rationale: Nurses should question patients frequently and explicitly. Avoiding talking about suicide is not helpful, and direct questions will not put ideas in the patient's head. Research demonstrates that direct questioning assists patients to feel less isolated and is the most effective way of assessing the actual risk. The use of safety agreements is controversial; they are not legal documents and compliance with a contract or safety agreement does not necessarily mean that patients will not hurt/kill themselves. Nurses should not provide false reassurance or apply judgment as in options c and d.

The nurse is providing teaching to the parents of a child receiving medication to treat a mental health disorder. The parents state that they found an article online stating the drug had not been approved for use in children. What common variable related to psychopharmacology with children should the nurse explain at this time? A. black box warnings B. off-label prescribing C. medical incompetence D. nonpharmacologic alternatives

Correct Answers: b Rationale: Off-label prescribing represents 50% to 75% of all pediatric psychotropic medication use. The practice refers to the permissible prescribing of medication to children and adolescents even though the Federal Drug Administration (FDA) has not specifically approved it for that use. Information related to safe administration is extrapolated from adult studies and integrated with knowledge related to the importance of monitoring children and adolescents for potential biophysical and neurodevelopmental alterations. It is important for the nurse to explain that this practice is common and to address related concerns. Black box warnings refer to medications that are FDA approved but whose use requires extra monitoring related to potentially dangerous or life-threatening side effects. Describing medical incompetence or nonpharmacologic interventions implies that the treatment is unsafe and or unwarranted and is not appropriate at this time.

The nurse is evaluating outcomes for a patient presenting in the emergency department for treatment after being sexually assaulted. The nurse understands that it is most essential that the care provided results in which outcome? A. the patient agrees to undergo counseling. B. the patient initiates criminal complaint. C. The patient's physical safety is maintained. D. The patient identifies the perpetrator of the assault.

Correct Answers: c Rationale: Maintaining the patient's safety while the patient is undergoing care is the priority. The nurse will also help the patient identify how to maintain safety following discharge from the emergency department. Undergoing counseling and initiating a criminal complaint may be helpful to the patient, but do not guarantee the patient's immediate safety. The patient may not be able to identify the perpetrator.

The nurse is working with a population of anxious and potentially aggressive patients. Which interpersonal factor is most essential to the nurse's capacity to promote a safe and effective care environment? A. absence of fear or anxiety B. composure and self-control C. assertive communication style D. ability to sacrifice safety for others

Correct Answers: b Rationale: The nurse caring for patients with a potential to be aggressive must be self-aware, recognizing situations that contribute to the nurse's own anxiety level. The nurse must also have the capacity to monitor personal reactions and maintain self-control and composure. Anxiety, fear, frustration, and anger are all normal emotions that the nurse must deal with effectively in order to avoid escalating or negatively influencing patients; it is unrealistic to expect them to be absent altogether. Assertiveness may be important, but it is less important than the ability to use coping mechanisms to reduce anxiety. Nurses need to engage in self-care and protection; a willingness to sacrifice their own safety does not contribute to a safe or therapeutic care environment.

The nurse working on an impatient mental health unit is attending to a colleague who was assaulted while caring for an agitated patient. The nurse recognizes that the colleague was a victim of which type of workplace violence? A. type I B. type II C. type III D. type IV

Correct Answers: b Rationale: The nurse's colleague was a victim of violence that occurred while conducting business; the patient or the perpetrator has a legitimate relationship with the healthcare staff. This type of workplace violence is categorized as Type II workplace violence.

The nurse is working on an inpatient psychiatric unit and notices a patient pacing with fists clenched. The nurse approaches the patient with the understanding that this behavior is usually a manifestation of which of the following? A. a lack of regard for others B. An unmet need with anxiety C. poor environmental controls and limits D. predatory instincts with cognitive deficits

Correct Answers: b Rationale: The patient pacing with fist clenched is demonstrating behaviors that are indicative of escalating anger and the potential for aggression. The nurse recognizes that this behavior most often represents an unmet need with anxiety. Efforts to de-escalate the patient would initially focus on trying to determine the unmet need and reducing the patient's anxiety. There is no evidence to indicate that the patient lacks regard for others or that environmental controls are inadequate. Predatory behaviors are characterized by deliberation and premeditation; in this case the patient is demonstrating behavior consistent with impulsive aggression.

A young adult patient is brought to a mental health center by his parents when he drops out of college at the end of the first semester. The patient reports living in a dorm that experienced a devastating fire that resulted in the death of several classmates and friends. The nurse recognizes that the patient is experiencing acute stress that is best categorized as which type of crisis? A. one in which an experience of other produces secondary trauma in the individual. B. one arising from an event that is beyond the scope of normal human experience. C. one that is a traumatic but inevitable, with death and loss of relationships. D. one that occurred in relationship to a developmental period where previously used coping skills no longer apply.

Correct Answers: b Rationale: The scope of loss experienced by this individual is best considered a large-scale experience that exceeds what most people encounter in a normal lifetime. As such, the nurse would recognize that the patient is experiencing an adventitious crisis. The patient actually experienced the crisis and is not responding to the impact of an event on significant others. While some exposure to death and loss of life is an inevitable part of life, experiencing this degree of loss at any one point is unusual and beyond the scope of a typical situational crisis. Although the patient is in a period of developmental transition, the inability to cope is related to a life event that would be expected to overwhelm and traumatize any individual regardless of developmental status.

The nurse is using the Level of Suicidal Severity Index to determine the level of risk for a patient. The patient states he often has fantasies about others coming to his funeral and feeling bad about how they have treated him. Although these thoughts make the patient feel better, he has no explicit plan in mind. The nurse determines that the patient is at which stage of suicide severity? A. Stage II: mild B. Stage III: moderate C. Stage IV: advanced D. Stage V: severe

Correct Answers: b Rationale: This individual has begun to consider suicide as an option for problem solving through thoughts that may be comforting or temporarily relieve the patient's suffering. At this point there is no specific plan. These findings are most consistent with Stage III: moderate thoughts of suicide based on the index developed by Green, Katz and Marcus (1995).

The nurse is participating in a psychological autopsy of a teenager who recently committed suicide. The nurse learns that the teenager immigrated with a family from another country, had begun to experience failing grades, had no friends, and was bullied by some classmates. under which wellness domains would the nurse most likely categorize behaviors and risks factors? Select all that apply. A. Biological B. Psychological C. Sociological D. Cultural E. Spiritual

Correct Answers: b, c, d Rationale: Based on the information provided, the nurse understands that the teen-ager had significant difficulty functioning in the psychological, sociological, and cultural domains. Impact on psychological functioning was evidenced by a loss of productivity or failing grades. Sociological functioning was compromised by isolation and exposure to interpersonal violence. Cultural function was affected by lack of connectedness to others who share the same cultural values and experiences. There is no evidence of biological factors or spiritual contributing to the completed suicide.

The nurses is caring for a patient with a somatic symptom disorder. The nurse reflects on her own feelings and beliefs about the disorder in order to provide nonjudgemental care. The rationale for this action relates most closely to which health/wellness domain? A. Cultural B. Spiritual C. Sociological D. Psychological

Correct Answers: c Rationale: Sociological aspects of somatic symptom disorders include feelings or isolation and a sense that no one understands their illness. Patients with this disorder often feel judged by others preventing them from accessing the resources necessary to manage the disorder. Nonjudgmental care is an essential aspect of assisting patients to overcome the stigma associated with the disorder.

The nurse is planning psychoeducational groups for patients. The nurse understands that the approach should be guided by which population-specific considerations? Select all that apply. A. children and adolescents will generally look toward adults for guidance and safety. B. adult men commonly withdraw from a crisis or simply avoid and or deny its effects. C. older adults tend to focus on social supports when confronted with a crisis situation. D. in comparison to younger adults, older adults are at more risk for a variety of situational crises. E. adults who care for aging parents are more susceptible to effects of a high cumulative stress burden.

Correct Answers: b, d, e Rationale: Adults, especially men, are more likely to use denial and avoidance to cope with a crisis. Older adults may have a diminishing pool of social supports and are more likely to experience situational crises such as the loss or illness of a loved one, financial scarcity, and retirement. Adults who care for aging parents may have their own homes, families, and jobs to contend with resulting in a higher cumulative burden of stressors. Although children may look toward adults for support, adolescents are usually more oriented to their peer group. Older adults are more likely to rely on their own resources and life experiences instead of focusing on social supports in a crisis

The nurse is working with a pregnant adolescent patient and her partner in the prenatal clinic. Which behaviors would alert the nurse to the possibility that the patient is a victim interpersonal violence? Select all that apply. A. the partner insists that they should get married after the baby is born. B. the patient states that her partner has made her cut off contact with all of her friends. C. the patient states that her partner did not want to terminate the pregnancy. D. the partner is extremely jealous of the attention that the unborn child is getting. E. the partner makes frequent derogatory comments about the patient's physical appearance.

Correct Answers: b,c,e Rationale: Warning signs for interpersonal violence include social isolation of the victim, extreme jealousy, and control and criticism or humiliation of the victim. The partner's insistence that they get married after the baby is born or the desire for the patient to have the baby do not necessarily indicate warning signs for abuse unless there is evidence that the patient is forced to concede against her will.

The nurse is assessing the patient with a history of severe trauma and abuse. Which finding alerts the nurse to the possibility of a dissociative disorder? A. The patient experiences symptoms of abnormal voluntary motor function. B. The patient's psychological symptoms affect the course of an associated medical illness. C. The patients reports recurrent gaps in the recall of everyday events and important information. D. The patient experiences excessive thoughts, feelings, or behaviors related to an associated health concern.

Correct Answers: c Rationale: Amnesia or gaps in the recall of everyday events in an individual with a history of severe trauma and abuse alert the nurse to a possibility of a dissociative disorder. Symptoms of abnormal voluntary motor function, psychological symptoms impacting a medical illness, and excessive thoughts and behaviors related to an associated health concern are more consistent with a somatic symptom disorder.

The nurse is working with a patient who is coping with a situational crisis related to the unanticipated loss of a job. The patient states, "I am failure and I will never be able to find another job." Which cognitive-behavioral approaches will best allow the nurse help the patient to optimize hope? A. Identifying any behaviors or attitudes that may contributed to the job loss. B. suggesting that the patient try to be more positive by using this time to enjoy other aspects of life C. encouraging the patient to identify other situations in which the patient has been able to successfully cope D. assisting the patient to develop a more realistic appraisal of the situation by minimizing the importance having a job

Correct Answers: c Rationale: By focusing on other areas in which the patient has been able to cope effectively, the nurse is promoting self-efficacy and the patient's sense that she will be able to manage the situation effectively. Focusing on behaviors that led to the loss of the job at this time may reinforce the patient's sense that she is not capable of overcoming the situation, and as an isolated intervention, will not help instill hope in the patient. While taking time to enjoy life may assist with stress reduction, it will not necessarily encourage the patient to be engage in healthy problem solving or be more optimistic about the future. Encouraging a realistic appraisal of the situation is important, but minimizing the importance of having a job itself is unrealistic and unlikely to promote adaptive functioning.

The nurse is considering evidence-based interventions with teenagers suffering from depression. The nurse is considering using Creating Opportunities for Personal Empowerment (COPE) as an intervention model. Which would be most appropriate for the nurse to identify as an expected outcome? A. participants explore traumatic events that may have contributed to mental health issues. B. participants recognize the importance of adhering to pharmacologic therapies to treat depression. C. participants identify and utilize adaptive strategies to cope with situations that are causing stress. D. participants use hourly sessions to talk about feelings and provide emotional support to one another.

Correct Answers: c Rationale: COPE is a cognitive-behavioral therapy-based intervention that can be delivered in 30 minutes to teens suffering from depression. The focus is on practical strategies to improve problem solving and the ability to cope with stress through healthy behaviors and positive thinking. The focus is not on exploring past traumas pharmacologic interventions or emotional expression and sessions are limited to 30 minutes.

The nurse is caring for a patient who has been a victim of physical abuse at the hands of a domestic partner. The nurse recognizes that which action by the patient places the patient at the greatest risk for imminent violence? A. begins planning for a safe exit B reports the abuse to authorities C. tells the partner that the relationship is over D. seeks treatment for physical injuries

Correct Answers: c Rationale: For an individual experiencing intimate partner violence, the time of greatest risk is when the individual ends the relationship. Nurses working with victims who are planning to leave abusive partners should help them plan for their safety as they leave the relationship.

The nurse is implementing evidence-based practice to reduce the incidence of injuries related to restraint and seclusion on the inpatient mental health unit. Which approach to patient care is most likely to be effective? A. providing for the direct supervision of any patient in restraints. B. ensuring that all personnel are properly trained in restraint techniques. C. emphasizing activities that build rapport and ensure that patient needs are met. D. warning patients frequently that if behaviors escalate, restraints will be used.

Correct Answers: c Rationale: The most effective way to reduce the incidence of injuries related to restraint and seclusion is to prevent them altogether. Because aggression often escalates from anxiety and an unmet need, it is important to build rapport with patients and maintain a supportive and responsive environment. Direct supervision and training around the use of restraints may minimize injuries, but are not as effective as preventing the need for their use altogether. Frequent warnings that restraints will be used as a consequence for aggression are unlikely to be effective, as this fails to address the anxiety and unmet needs that precipitate violence.

The parents of a 4 year old child receiving treatment for mental health issues ask the nurse, "what good is it doing out child to spend all this time playing with the therapist?" Which response by the nurse is most appropriate? A. "It is difficult to comment on activity that is not within my area of nursing expertise." B. "Play helps your child to see the therapist as a friend so your child will open up and talk freely." C. "Play is developmental activity that is used to help children learn to solve problems and cope with difficult experiences." D. "If you don't fell this type of therapy is a good fit for your child, you should request a different type of therapist."

Correct Answers: c Rationale: The primary purpose of play therapy is to work through feelings, conflicts, and stress. Play is a developmental activity that supports mastery and social, emotional, and intellectual growth. The nurse's role is to support collaborative interventions and to have an understanding of therapeutic modalities used by other health professionals. Although play may assist in the development of a relationship and support the sharing of feelings, the goal is not for the child to see the therapist as a friend. The nurse is being asked to provide information, and it is not appropriate to suggest that the parents find another therapist at this time.

The nurse is performing an assessment of a patient who had just experienced an acute crisis. Which action is priority? A. validating the patients perception of what has just occurred B. classifying the type of trauma that the patient has experienced C. eliminating any immediate physiological and psychological threats D. determining which type of treatment interventions will be necessary

Correct Answers: c Rationale: The priority intervention is to ensure the patient's immediate physiological and psychosocial safety. Once the patient's safety has been established and threats have been eliminated, the nurse can proceed to classifying the trauma, articulating the patient's perception of the trauma, and determining appropriate treatment interventions.

The community health nurse is working on an initiative to decrease the incidence of suicides in a neighborhood. Based on national statistics, which individual would be places in the highest risk category? A. The 25-year old African American female who is employed and a single parent. B. The 15- year old male high school student who volunteers for a hospice organization C. The 34- year old Native American male, who is recently married and has a history of military duty D. The 88year-old Caucasian male who is recently widowed and has chronic congestive heart failure

Correct Answers: d Rationale: Although persons of any age, sex, ethnicity or socioeconomic status may be at risk for suicide, based on statistics, the older adult male who is recently widowed and has a chronic cardiac condition is at greatest risk for completed suicide. Females are less likely to complete suicide, and African American females have a slightly lower incidence of completed suicide. Having a child is considered a protective factor. Although the incidence of completed suicides higher in adolescent males, there are no other variables that represent a risk for the adolescent patient described, and caring for others is also a protective factor. Native American youth between 15 and 24 have a higher incidence of completed suicide, and this individual is older and is married (a protective factor). A history of military duty may or may not include exposure to trauma or violence.

The nurse community health nurse is working on an initiative to reduce the incidence of violence in an inner city, impoverished neighborhood. Which evaluation finding best indicates that a risk factor for community violence has been addressed? A. more affluent citizens begin to populate the area. B. funding is obtained for neighborhood beautification. C. disenfranchised youth are bused to better school systems. D. members take advantage of opportunities for cohesion and engagement.

Correct Answers: d Rationale: Although there is some controversy regarding the etiology of community violence, several factors are thought to impact the risk for community violence. These include cohesion, collective action, poverty, and inequality. By utilizing opportunities for cohesion and engagement, community members can take constructive action to ameliorate a number of factors contributing to community violence. More affluent citizens moving into the area may actually exacerbate inequality. Neighborhood beautification may increase pride, but it does not address underlying factors that lead to violence. Busing disenfranchised youth to better school systems does not necessarily decrease the incidence of violence, which occurs across the lifespan and in the context of the community setting.

The nurse is caring for a patient experiencing a somatic symptom disorder. The patient's family member asks is there are any medications that can treat the underlying cause of the disorder. How should the nurse respond? A. "The treatment of choice is intensive, long-term talk psychotherapy." B. "Antidepressants and anti anxiety agents are the treatment of choice." C. "Somatic symptoms repsond to the same medication used to treat medical condition with the same symptoms." D. "Cognitive-behavioral therapy and collaborative health care interventions are used to treat the disorder."

Correct Answers: d Rationale: Cognitive-behavioral therapy and collaborative interventions are the treatment of choice for patients experiencing a somatic symptom disorder. Antianxiety and antidepressant medications are used to treat associated anxiety or depressive disorders but are not used to treat the somatic symptom disorder.. While medication may be used to manage any concurrent medical issues, they are not advised for patients with somatic symptom disorders.

The nurse is assessing a patient who has just experienced a significant loss. Which question is likely to elicit the best information related to functional status? A. "How have you been coping?" B. "Are you currently employed?" C. "Who do you rely on for help?" D. "How do you make sense of this loss?"

Correct Answers: d Rationale: Functional status refers to the patient's ability to manage activities necessary to meet basic needs. Asking about the patient's coping strategies will provide the best information on the patient's ability to function in the face of the loss. A question about current employment does not necessarily relate to functional status. Asking who the patient relies on for help addresses support systems but does not necessarily provide information on functional status. Asking how the patient is making sense of the loss relates more to an evaluation of the spiritual impact of the loss.

The nurse is evaluating the effectiveness of interventions aimed at addressing spiritual distress in a patient who has experienced a significant loss. Which finding best indicates resolution of the distress? A. the patient recognizes that she is not to blame. B. the patient acknowledges the cause of the distress. C. the patient carries out religious activities and rituals. D. the patient identifies a positive purpose related to the loss.

Correct Answers: d Rationale: Grieving individuals may find that their beliefs are challenged when an event that doesn't make sense or seem fair occurs. Nursing interventions are aimed at assisting the patient to find meaning in the event; the identification of a positive purpose provides the best indication of resolution of the crisis. Guilt and self-blame may be associated with survivor guilt, but the recognition that the individual is not to blame does not necessarily mean that the underlying spiritual distress has resolved. Acknowledging the cause of the distress is important but does not demonstrate the ability to find a meaning or purpose in the event. Carrying out religious activities or rituals does not necessarily mean that spiritual distress has been resolved or that these activities are a source of comfort or support for the individual

The nurse is assessing a patient for factors contributing to a grief response. Which would the nurse recognize as being an intangible loss? A. marriage ending in divorce B. moving out of a childhood home C. recent unemployment D. feelings of insecurity following a traumatic event

Correct Answers: d Rationale: Intangible losses are those losses that are not physical, visible, and easily recognized. The loss of security following a traumatic event is an example of an intangible loss. Divorce, developmental losses, and the loss of a job are examples of tangible losses that can be experienced by a patient.

The nurse is evaluating the classroom setting for modifications used to support a group of children with reactive temperament style. Which finding would be of most concern? A. advanced notice of fire drills is provided. B. open-ended activities are kept to a minimum. C. children are asked to raise their hands before speaking D. highly stimulating activities are used to promote engagement.

Correct Answers: d Rationale: Temperament is an inherited, genetically determined variable that interfaces with the environment to contribute to behavioral responses. The child with a reactive temperament style is unlikely to respond positively to highly stimulating activities. Advance notice of fire drills, keeping open-ended activities to a minimum, and asking children to raise their hands before speaking are examples of environmental modifications that promote predictability and structure and would be appropriate for a group of children with this temperamental style.

The nurse is caring for patient with a history of injury to the frontal lobe of the brain. The nurse recognizes that the impact of this injury on the ability to manage aggressive impulses results from an alteration in which key neurological function? A. stimulation of the limbic axis B. hypothalamic hormone release C. the responsiveness of the amygdala D. executive function and inhibition of impulse.

Correct Answers: d Rationale: The prefrontal cortex is responsible for executive function and top down inhibition of threatening stimuli, which activate the HPA axis and produce a flight or fight response. An injury to the frontal lobe may result in problems with executive function and the ability to inhibit aggressive impulses.

The nurse is caring for the patient in the early stages of Alzheimer disease. Which evaluation finding indicates that treatment with citalopram (Celexa) has been effective? A. improved mood B. continued independence in performing ADLs C. no symptoms of psychosis D. restored memory

Correct answers: a Rationale: Citalopram (Celexa) is a selective serotonin-reuptake inhibiter (SSRI) that may improve emotional symptoms of Alzheimer disease, including mood and anxiety. Cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) receptor antagonists are used to slow the progression of the disease including decline on cognitive function. Antipsychotic medications are used to manage hallucinations and psychosis. Citalopram does not restore memory, and there are currently no medications that reverse or permanently arrest the progression of the disease.

The nursing is planning care for the patient with Alzhiemer disease. Which rationale best supports spending time with the patient, reviewing photo albums and talking about important life events? A. Life review activities can promote the patient's comfort and sense of connectedness. B. "Remembering" exercises have been shown to improve both short-term and long-term memory. C. Reminiscence therapy can assist the nurse to overcome burnout and see the patient as an individual. D. discussing life events provides a nonintrusive way for the nurse to gather critical assessment data.

Correct answers: a Rationale: Literature supports the use of reminiscence therapy as a means to promote self-esteem, reduce feelings of isolation, and provide comfort and reassurance to patients with deficits in short term memory. It is used when long-term memory is still intact and does not necessarily improve memory. Although this activity can assist nurses to provide compassionate care and or obtain more assessment data, the primary purpose of this activity is the immediate comfort and wellbeing of the patient.

The emergency department nurse is assessing an older adult patient who presents disoriented, with rambling speech and disorganized thinking. Which additional findings would support the nurse's suspicion that the patient is suffering from delirium? Select all that apply. A. hallucinations B. Insidious onset C. Hyper-vigilance D. Depressed affect E. Altered consciousness

Correct answers: a, b, c, e Rationale: Altered consciousness, sensory disturbances, hallucinations, excitability, agitation, and hypervigilance are hallmarks of delirium, an acute condition requiring emergency intervention. Depression, apathy, and a slow, insidious onset are characteristic of dementia.

The nurse is caring for a patient with dementia. The patient is undergoing a comprehensive medical evaluation to determine the primary disorder. Which clinical manifestations suggest a condition other than Alzheimer disease? Select all that apply. A. difficulty with speech B. abnormal movements C. rapid onset and progression D. socially inappropriate behavior E. disturbance in executive function

Correct answers: a,b,c Rationale: Socially inappropriate behavior and disturbance in executive function are both characteristic of Alzheimer disease. Difficulty with speech, abnormal movements, and rapid onset and progression of the illness suggest another neurocognitive disorder such as vascular dementia, encephalopathy, Huntington disease, or Parkinson disease.

The nurse is caring for a patient in stage 2 of Alzheimer disease. Which interventions are appropriate at this time? Select all that apply. A. installing door locks B. providing memory aids C. encouraging regular exercise D. covering or removing mirrors E. establishing advance directives

Correct answers: b, c, e Rationale: Stage 2 of Alzheimer disease is characterized by mild cognitive impairment in one or more abilities. Because the patient is still able to function independently and participate in decision making, establishing advance directives, providing memory aids, and encouraging regular exercise are all appropriate interventions. Patients with dementia who are in advance stages of the disease may require more a more restrictive environment or interventions such as putting locks on the doors. Covering mirrors can reduce anxiety and fear in patients who do not recognize themselves in the mirror, which may be seen during the late stages of Alzheimer disease.

The nurse is providing education to the adult children of a patient diagnosed with late-onset Alzhiemer disease. One of the children asks, "Does this mean that we will get this disease too?" Which response is accurate? A. "research shows that only early-onset Alzheimer disease runs in families." B. "Not unless you have been exposed to the same environment toxins." C."A familial pattern may increase the likelihood of developing the disease." D. "If we live long enough, eventually we will all develop some for of the disorder."

Correct answers: c Rationale: Biological factors, including genetic influences, are believed to cause Alzheimer disease. Environmental factors contributing to Alzheimer disease are not well understood, so it is inappropriate to tell family members that they will not develop the disease unless they have been exposed to the same conditions. Early-onset cases are believed to be more heritable than late onset cases, but there is evidence that certain genes are implicated in both forms of the disorder. While living longer may increase the likelihood of developing the disease, it is inaccurate to state that all people who live to old age will develop Alzheimer disease.

The nurse is admitting an 82-year old adult presenting to the acute care setting with sudden onset of confusion. Which is the priority nursing action? A. determining whether there is a family history of Alzheimer disease. B. Evaluating the safety of the home/living environment. C. Initiating assessments to rule out an underlying physiological cause. D. Assessing for any missed signs of progressive functional decline.

Correct answers: c Rationale: In the older adult population, a sudden onset of confusion or delirium signals an underlying, possibly life-threatening condition that can be reversed with prompt intervention. Taking action to rule out the possibility of a physiological cause for the delirium is the priority. Alzheimer's disease is generally progressive. The safety of the home environment is not an immediate concern. A more detailed history can be obtained once the possibility of a more urgent underlying cause has been addressed.

The staff nurses at a local psychiatric unit are participating in a skills refresher day. The nurse manager is presenting information for the staff regarding the different types of workplace aggression. What information will the nurse manager include in the teaching, when discussing prevention of the various types of workplace aggression? 1. Installing metal detectors at the hospital entrance may help to prevent type IV aggression 2. Promoting and establishing interpersonal relationships may help to prevent type III aggression 3. Improving the lighting in the parking lot of the hospital may help to prevent type II aggression 4. Limiting the number of visitors and family members in the hospital may help to prevent type I aggression

Explanation: 2. Promoting and establishing interpersonal relationships may help to prevent type III aggression. Type III aggression occurs when the perpetrator has or had a formal employment relationship with the victim. By developing interpersonal relationships among employees, this type of aggression may be prevented. Installing metal detectors and improving outside lighting may best prevent type I aggression, which occurs when the perpetrator has no relationship to the victim. An example of a type I violent act is a nurse or staff member being attacked by a stranger in the hospital parking lot. Limiting the number of visitors and family members in the hospital may help to prevent type II aggression, which occurs when the perpetrator has a legitimate relationship with the business. An example of a type II violent act is an emergency department receptionist being attacked by a family member of a patient.

A nurse is caring for a client following the loss of her partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in order of occurrence. All steps must be used.) A. Developing awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

Step 1: C. Shock and disbelief is the first stage in Engel's five stages of grief. In this stage the client experiences a sense of numbness and denial over the loss. Step 2: A. Developing awareness is the second stage in Engel's five stages of grief. In this stage the client becomes aware of the reality of the loss resulting in intense feelings of grief. This begins within hours of the loss. Step 3: B. Restitution is the third stage in Engel's five stages of grief. In this stage the client carries out cultural/ religious rituals, such as a funeral, following the loss. Step 4: E. Resolution of the loss is the fourth stage in Engel's five stages of grief. In this stage the client is preoccupied with the loss. This preoccupation gradually decreases over about a 12 month time period. Step 5: D. Recovery is the fifth and final stage in Engel's five stages of grief. In this stage the client moves past the preoccupation with the loss and moves forward with life.

The nurse is providing teaching to the family caring for a patient who is at risk for suicide. What should the nurse emphasize? Select all that apply. A. Differentiating between real threats and manipulative behavior B. understanding that suicide is usually related to family dysfunction C. The importance of reaching out to hotlines, crisis care centers, or emergency departments D. Recognizing the direct and indirect warning signs that are often present before a suicide attempt

c, d, e Rationale: The nurse recognizes the impact of families caring for a member with suicidal behavior and would recommend professional support and counseling. Further teaching would incorporate accessing emergency intervention and recognizing warning signs. Family members would not be asked to differentiate between real threats or manipulation because all threats should be taken seriously. Suicide in a family member does not necessarily indicate the presence of family dysfunction.