MH Exam 2

26. Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with dissociative identity disorder. Disturbed personal identity related to a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

22. A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

ANS: D PTSD precipitates changes that can lead to divorce. It is important to provide support to both the veteran and spouse. Confrontation will not be effective. While it is important to provide information, on-going support will be more effective.

21. A parent says, "My son and I argue constantly since he started using drugs. When I talk to him about not using drugs, he tells me to stay out of his business." What is the nurse's first most appropriate action? a. Educate the parent about stages of family development. b. Report the son to law enforcement authorities. c. Refer the son for substance abuse treatment. d. Make a referral for family therapy.

ANS: D Family therapy is indicated, and the nurse should provide a referral. Reporting the child to law enforcement would undermine trust and violate confidentiality. The other distracters may occur later.

16. A family expresses helplessness related to dealing with a mentally ill member's odd behaviors, mood swings, and argumentativeness. An effective nursing intervention for this family would be to a. express sympathy for their situation. b. involve local social service agencies. c. explain symptoms of relapse. d. role-play difficult situations.

ANS: D Helping a family learn to set limits and deal with difficult behaviors can often be accomplished by using role-playing situations, which give family members the opportunity to try new, more effective approaches. The other options would not provide learning opportunities.

Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat underlying depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

B Various types of antidepressants may be helpful in somatic disorders directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood, but fatigue, pain perception, GI distress, and other somatic symptoms. Patients may benefit from short-term use of anti-anxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated.

A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? a.A patient diagnosed with schizophrenia is not usually overtly psychotic. b.In schizotypal personality disorder, the patient remains psychotic much longer. c.With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d.Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

with schizotypal personality disorder, the person can be made aware of misinterpretations of reality

Match the group member's comment to the role it most closely represents. a. Playboy b. Energizer c. Organizer d. Follower 1. "We aren't getting much done; let's speed things up and make a decision." 2. "Last week we finished our first goal and today we are starting on our second." 3. "Everyone has had good ideas so far; so, whatever you say is fine with me." 4. "It doesn't really matter what we do. I'm just here because they make me attend."

1. ANS: B 2. ANS: C 3. ANS: D 4. ANS: A

Which presentations suggest the possibility of a factitious disorder, self-directed type? Select all that apply. a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries c. Going from one doctor to another seeking the desired response d. Claims illness to obtain financial benefit or other incentive e. Difficulty describing symptoms

A, B Persons with factitious disorders, self-directed type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. If they do not receive the desired response from a hospitalization, they may elope or accuse staff of incompetence. Such persons usually seek treatment through a consistent health care provider rather than doctor-shopping, are not motivated by financial gain or other external incentives, and present symptoms in a very detailed, plausible manner indicating considerable understanding of the disorder or presentation they are mimicking. See relationship to audience response question.

9. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

ANS: A Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment.

2. A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? a. "I will tell myself that I am a good person when things don't go well at work." b. "My medications will make my problems go away." c. "My family will help take care of my children while I am in the hospital." d. "This therapy will improve my response to neurotransmitter impulses."

ANS: A Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy. Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects a. guilt. b. denial. c. shame. d. rescue feelings.

ANS: A The parents' statements indicate guilt. Guilt is evident from the parents' self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

24. A patient approaches the nurse in the clinic waiting room and says, "I want to talk to you about a sexual matter." The nurse can best facilitate the discussion by a. saying, "Let's go my office." b. responding, "I want to help. Go ahead; I'm listening." c. telling the patient, "Let's schedule another appointment." d. offering to sit in a corner of the waiting room with the patient.

ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The distracters block communication.

11. Which season would be most associated with increased periods of wakefulness in the general population? a. Summer b. Winter c. Spring d. Fall

ANS: A Circadian drive is associated with physiology. Light is the main exogenous factor that drives wakefulness. Days are longest in summer.

19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

ANS: A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.

3. An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.) a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer

ANS: A, B, C Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence.

1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? (Select all that apply.) a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

ANS: A, B, D Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

17. A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

ANS: B Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.

16. Which CAM method is associated with using allergy injections of small amounts of an allergen in solution? a. Naturopathy b. Homeopathy c. Chiropractic d. Shiatsu

ANS: B Homeopathy uses small doses of a substance to stimulate the body's defenses and healing mechanisms to treat illness. Naturopathy emphasizes health restoration rather than disease. Chiropractic uses manipulation of the body to restore health. Shiatsu is a type of massage.

9. A person is prescribed lorazepam 2 mg PO bid as needed for anxiety. When the person takes this medication, which change in sleep is anticipated? The patient will a. have fewer dreams. b. have less slow-wave sleep. c. experience extended sleep latency. d. enter sleep through REM sleep.

ANS: B Lorazepam is a benzodiazepine, which reduces slow-wave sleep. REM sleep would likely increase. Persons with narcolepsy often enter sleep through REM.

5. An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects

ANS: B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.

21. Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization

ANS: B The patient's statements reflect self-blame, an unhealthy coping mechanism. The patient's statements do not reflect rationalization, suppression, or projection.

1. Which neurotransmitters are most responsible for wakefulness? (Select all that apply.) a. -aminobutyric acid (GABA) b. Norepinephrine c. Acetylcholine d. Dopamine e. Galanin

ANS: B, C, D The neurotransmitters responsible for wakefulness are dopamine, norepinephrine, serotonin, acetylcholine, histamine, glutamate, and hypocretin. GABA and galanin are sleep-promoting neurotransmitters.

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

2. An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

ANS: C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

6. A patient says, "It takes me about 15 minutes to go to sleep each night." This comment describes a. delta sleep. b. parasomnia. c. sleep latency. d. REM sleep.

ANS: C Sleep latency refers to the amount of time it takes a person to fall asleep. The distracters represent other phases of the sleep cycle.

13. A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.

6. Which information is the nurse most likely to find when assessing the family of a patient with a serious mental illness? a. The family exhibits many characteristics of dysfunctional families. b. Several family members have serious problems with their physical health. c. Power in the family is maintained in the parental dyad and rarely delegated. d. Stress from living with a mentally ill member has challenged the family's function.

ANS: D The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family's level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional.

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."

ANS: D The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

10. A person is prescribed sertraline 100 mg PO daily. Which change in sleep is likely secondary to this medication? The patient will have a. more dreams. b. excessive sleepiness. c. less slow-wave sleep. d. less REM sleep.

ANS: D Sertraline (Zoloft) is an SSRI antidepressant medication, which suppresses REM sleep. Dreams would decrease because they occur during REM. Benzodiazepines reduce slow-wave sleep. SSRIs have a side effect of insomnia.

14. A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a.Narcissistic b.Histrionic c.Avoidant d.Paranoid

Avoidant

A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed self after explaining arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self. d. address needs of other patients in the dining room, then feed this patient.

B The patient is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a."I think you are the best nurse on the unit." b."I'm never going to get high on drugs again." c."I felt empty and wanted to hurt myself, so I called you." d."I hate my mother. I called her today, and she wasn't home."

I felt empty and wanted to hurt myself, so i called you

A person's spouse filed charges after repeatedly being battered. The person sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by this person supports an antisocial personality disorder? a."I have a quick temper, but I can usually keep it under control." b."I've done some stupid things in my life, but I've learned a lesson." c."I'm feeling terrible about the way my behavior has hurt my family." d."I hit because I am tired of being nagged. My spouse deserves the beating."

I hit because im tired of being nagged. my spouse deserves the beating

A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select the nurse's most therapeutic response. a."Let's consider the advantages of being able to stop and think before acting." b."It sounds as though you've developed some insight into your situation." c."I bet you have some interesting stories to share about overreacting." d."It's good that you're showing readiness for behavioral change."

Lets consider the advantages of being able to stop and think before acting

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a.Supporting behavioral change b.Maintaining consistent limits c.Monitoring suicide attempts d.Using aversive therapy

Maintaining constant limits

A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will a.adhere willingly to unit norms. b.report decreased incidence of self-mutilative thoughts. c.demonstrate fewer attempts at splitting or manipulating staff. d.demonstrate ability to introduce self to a stranger in a social situation.

demonstrate ability to introduce self to a stranger ins a social situation

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to a.an inherited disorder that manifests itself as an incapacity to tolerate stress. b.use of projective identification and splitting to bring anxiety to manageable levels. c.a constitutional inability to regulate affect, predisposing to psychic disorganization. d.fear of abandonment associated with progress toward autonomy and independence.

fear of abandonment with progress towards autonomy and independence

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are a.affable, generous. b.perfectionist, inflexible. c.suspicious, holds grudges. d.dramatic speech, impulsive.

perfectionist, inflexible

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should a.maintain a stern and authoritarian affect. b.provide care in a matter-of-fact manner. c.encourage the patient to express anger. d.be very rigid and challenging.

provide care in a matter of fact manner

For which behavior would limit setting be most essential? The patient who a.clings to the nurse and asks for advice about inconsequential matters. b.is flirtatious and provocative with staff members of the opposite sex. c.is hypervigilant and refuses to attend unit activities. d.urges a suspicious patient to hit anyone who stares.

urges a suspicious patient to hit anyone who stares

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a.Flattering the nurse b.Lying to other patients c.Verbal abuse of another patient d.Detached superficiality during counseling

verbal abuse of another patient

Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. "My employer should have paid for a health club membership for me." b. "My family will see me through this. It won't be easy, but I will never be alone." c. "My heart attack was no fun, but it showed me up the importance of a good diet and more exercise." d. "I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily."

A Blaming someone else and rationalizing one's failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one's situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition.

22. A nurse leads a psychoeducational group for patients in the community diagnosed with schizophrenia. A realistic outcome for group members is that they will a. discuss ways to manage their illness. b. develop a high level of trust and cohesiveness. c. understand unconscious motivation for behavior. d. demonstrate insight about development of their illness.

ANS: A Patients with schizophrenia almost universally have problems associated with everyday living in the community, so discussing ways to manage the illness would be an important aspect of psychoeducation. Discussing concerns about daily life would be a goal to which each could relate. Developing trust and cohesion is desirable but is not the priority outcome of a psychoeducational group. Understanding unconscious motivation would not be addressed. Insight would be difficult for a patient with residual schizophrenia because of the tendency toward concrete thinking.

26. A 16-year-old wants to drive, but the parents will not allow it. A 14-year-old sibling was invited to several sleepovers, but the parents found reasons to deny permission. Both teens are annoyed because the parents buy clothes for them that are more suitable for younger children. The parents say, "We don't want our kids to grow up too fast." Which term best describes this family's boundaries? a. Rigid b. Clear c. Enmeshed d. Differentiated

ANS: A Rigid boundaries are those that do not change or flex with changing circumstances, as indicated here by parents who are reluctant to revise their roles and expectations about their children as the children mature. Enmeshed boundaries are those that have failed to differentiate or develop individually; the family shares roles and thoughts to an excessive degree, without a healthy degree of individuality. Clear boundaries are not enmeshed; they are appropriate and well maintained.

13. Three members of a therapy group share covert glances as other members of the group describe problems. When one makes a statement that subtly criticizes another speaker, the others nod in agreement. Which group dynamic should the leader suspect? a. Some members are acting as a subgroup instead of as members of the main group. b. Some of the members have become bored and are disregarding others. c. Three members are showing their frustration with slower members. d. The leadership of the group has been ineffective.

ANS: A Subgroups, small groups isolated within a larger group and functioning separately from it, sometimes form within therapy groups. When this occurs, subgroup members are cohesive with other subgroup members but not with the members of the larger group. Members of the subgroup may be bored or frustrated or expressing passive aggression, but the primary dynamic is the splitting off from the main group.

A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? Select all that apply. a. Female b. Reports frequent syncope c. Rates pain as "1" on a scale of "10" d. First diagnosed with psoriasis at age 12 e. Reports insomnia often results from back pain

A, B, E There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain

17. Parents of a mentally ill teenager say, "We have never known anyone who was mentally ill. We have no one to talk to because none of our friends understand the problems we are facing." Select the nurse's most helpful intervention. a. Refer the parents to a support group. b. Build the parents' self-concept as coping parents. c. Teach the parents techniques of therapeutic communication. d. Facilitate achievement of normal developmental tasks of the family.

ANS: A The need for support is evident. Referrals are made when working with families whose needs are unmet. A support group will provide the parents with support of others with similar experiences and with whom they can share feelings and experiences. The distracters are less relevant to providing a network of support.

23. Which assessment finding best supports dissociative fugue? The patient states a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

ANS: A The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

A patient diagnosed with a somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

A, E The patient's verbalization is consistent with spiritual distress. The patient's description of being unable to provide for and burdening the family indicates ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

4. During group therapy, one patient says to another, "When I first started in this group, you were unable to make a decision, but now you can. You've made so much progress that I am beginning to think maybe I can conquer my fears too." Which therapeutic factor is evident by this statement? a. Hope b. Altruism c. Catharsis d. Cohesiveness

ANS: A The patient's profession that he may be able to learn to cope more effectively reflects hope. Groups can instill hope in individuals who are demoralized or pessimistic. Altruism refers to doing good for others, which can result in positive feelings about oneself. Catharsis refers to venting of strong emotions. Cohesion refers to coming together and developing a connection with other group members.

23. A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with boys who are athletic d. Intense urges to watch his parents have sex

ANS: A An individual with gender dysphoria feels at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender dysphoria.

11. Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

ANS: A Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

17. A nurse plans health education for a patient who will be receiving warfarin for several weeks after knee-replacement surgery. Which substance should the nurse caution the patient to avoid? a. Fish oil b. Black cohosh c. Lavender d. Mandarin

ANS: A Fish oil may increase bleeding time and therefore has a potentially hazardous interaction with the anticoagulant warfarin. Black cohosh is an herbal treatment for hot flashes. Mandarin and lavender may have calming effects, which may be helpful, but would not cause increased risk of bleeding.

14. Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

12. A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: A In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.

9. The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

8. Which person would be most likely to experience sleep fragmentation? a. An obese adult b. A toddler who attends day care c. A person diagnosed with mild osteoarthritis d. An adolescent diagnosed with anorexia nervosa

ANS: A Obese adults experience more disruption of sleep stages, resulting in fragmentation. Obesity is the leading factor for obstructive sleep apnea, which causes sleep fragmentation. These changes are also associated with illness and some medications. The changes are evident on a hypnogram. An adolescent with anorexia nervosa would have a low body weight and therefore decreased risk for sleep fragmentation. Persons with arthritis have pain that may sometimes interrupt sleep, but it would not have as high risk as would obesity. Toddlers do not generally experience sleep fragmentation.

15. One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36 C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5 C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7 C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight NURSINGTB.COM within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

22. During an assessment interview, a patient diagnosed with inflammatory bowel disease accompanied by frequent episodes of diarrhea says, "I've been using probiotics in small doses for about a week." When the nurse assesses mental status, expected findings would be a. intact cognitive function. b. slow verbal responses. c. paranoid thinking. d. slurred speech.

ANS: A Probiotics may reduce inflammation and heal the gut. No effect on cognitive function would be associated with use of microbiomes, including probiotics. The patient has taken small doses, so response times would be normal. It does not usually produce the effects cited in the distracters.

13. After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

ANS: A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety.

3. The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority? a. "It's important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents." b. "Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year." c. "Turn the radio on with a soft volume as you prepare for bed each evening. It will help you relax." d. "Three glasses of wine each evening helps many patients who suffer from sleep deprivation."

ANS: A Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. Alcohol compounds problems associated with sleep deprivation. Sleep deprivation should be evaluated and treated; a 1-year delay is too long.

1. A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. PTSD e. Reactive attachment disorder f. Disinhibited social engagement disorder

ANS: A, B, D Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.

4. A patient reports frequent sleep disturbances. Which interventions could be considered to help improve the patient's sleep pattern? (Select all that apply.) a. Melatonin b. Chamomile c. Vitamin C d. Valerian e. SAM-e

ANS: A, B, D Melatonin, chamomile, and valerian have relaxant effects that help sleep. SAM-e may help with mild depression. Vitamin C has no effect on sleep.

2. A night shift worker reports, "I'm having trouble getting to sleep after a night's work. I have a hearty breakfast with coffee, read the paper, do my exercises, and then go to bed. However, I just lie awake until it is nearly time to get up to be with my family for dinner." What changes should the nurse suggest? (Select all that apply.) a. Drink juice with breakfast rather than coffee. b. Exercise after awakening rather than before. c. Turn on the television when going to bed. d. Do not read the paper. e. Eat a light breakfast.

ANS: A, B, E Sleep can be disrupted by caffeine, a CNS stimulant, exercise performed just before trying to sleep, and eating a heavy meal before retiring. Reading the newspaper is not likely to be so stimulating that it disrupts the patient's ability to sleep. Television will be disruptive to sleep.

3. Which situations are most likely to place severe, disabling stress on a family? (Select all that apply.) a. A parent needs long-term care after sustaining a severe brain injury. b. The youngest child in a family leaves for college in another state. c. A spouse is diagnosed with liver failure and needs a transplant. d. Parents of three children, aged 9, 7, and 2 years, get a divorce. e. A parent retires after working at the same job for 28 years.

ANS: A, C, D Major illnesses and divorce place severe, potentially disabling stress on families. The distracters identify normal milestones in a family's development.

12. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's Disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

8. Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

27. An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

3. When a nurse assesses a family, which family task has the highest priority for healthy family functioning? a. Allocation of family resources b. Physical maintenance and safety c. Maintenance of order and authority d. Reproduction of new family members

ANS: B Physical and safety needs have greater importance in Maslow's hierarchy than other needs.

17. An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.

ANS: B Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiological stability. The distracters are of lower priority than preserving physiological functioning.

11. A patient has tried a variety of CAM approaches to manage health concerns. The nurse asks, "How is going to CAM practitioners different from seeing your medical doctors?" The patient is most likely to respond, "The CAM practitioners a. usually prescribe a course of invasive and sometimes painful treatments." b. spend more time talking with me and not just about my symptoms." c. say I need to become much more spiritual to be well." d. order many tests to determine my diagnoses."

ANS: B CAM practitioners often spend considerable time assessing the person in a holistic way. Visits typically involve lengthy discussions, in contrast to traditional physician visits, where contact is often brief. CAM remedies can sometimes be invasive or slightly painful, but usually they are noninvasive and well-tolerated. Some CAM practices are very spiritually focused, but most do not have overt religious elements. Conventional health care involves more diagnostic testing than CAM.

16. An older adult diagnosed with Alzheimer's disease lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse? a. Multiple caregivers b. Alzheimer's disease c. Living in a rural area d. Being part of a busy family

ANS: B Older adults are at high risk for violence, particularly when there is significant dependency such as would be expected with dementia or other cognitive impairments. The incorrect responses are not identified as placing an individual at high risk.

14. Which situation demonstrates use of primary intervention related to crisis? a. Implementation of suicide precautions for a depressed patient b. Teaching stress-reduction techniques to a first-year college student c. Assessing coping strategies used by a patient who attempted suicide d. Referring a patient diagnosed with schizophrenia to a partial hospitalization program

ANS: B Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

10. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? a. Defensive coping b. Sexual dysfunction c. Ineffective sexuality pattern d. Disturbed sensory perception, tactile

ANS: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping.

3. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

17. A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

22. Which scenario best demonstrates a healthy family? a. One parent takes care of children. The other parent earns income and maintains the home. b. A family has strict boundaries that require members to address problems within the family. c. A couple requires their adolescent children to attend church services three times a week. d. A couple renews their marital relationship after their children become adults.

ANS: D Revamping the marital relationship after children move out of the family of origin indicates the family is moving through its stages of development. Strict family boundaries or roles interfere with flexibility and use of outside resources. Adolescents should have some input into deciding their activities.

2. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

ANS: D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

9. The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.

To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority: a. explain the pathophysiology of symptoms. b. help these patients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d. investigate each physical symptom as it is reported.

C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that the patient would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the patient reports them.

What is an essential difference between somatic symptom disorders and factitious disorders? a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.

D The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question.

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a.Ability to achieve true intimacy b.Flexibility and adaptability to stress c.Ability to provoke interpersonal conflict d.Inability to develop trusting relationships

ability to provoke interpersonal conflict

What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will a.identify when feeling angry. b.use manipulation only to get legitimate needs met. c.acknowledge manipulative behavior when it is called to his or her attention. d.accept fulfillment of his or her requests within an hour rather than immediately.

acknowledge manipulative behavior when it is called to her or her attention

What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a.Risk for other-directed violence b.Risk for self-directed violence c.Impaired social interaction d.Ineffective denial

risk for other directed violence

4. Which documentation of family assessment indicates a healthy and functional family? a. Members provide mutual support. b. Power is distributed equally among all members. c. Members believe there are specific causes for events. d. Under stress, members turn inward and become enmeshed.

ANS: A Healthy families nurture and support their members, buffer against stress, and provide stability and cohesion. The distracters are unrelated or incorrect.

21. The principle most useful to a nurse planning crisis intervention for any patient is that the patient a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has high potential for self-injury.

ANS: A Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis.

7. Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

5. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patient's safety.

15. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our child acts so strangely that we don't invite friends to our home. We quit taking vacations. Sometimes we don't get any sleep." Which nursing diagnosis best applies? a. Impaired parenting b. Parental role conflict c. Impaired social interaction d. Interrupted family processes

ANS: D Interrupted family processes are evident in the face of disruptions in family functioning as a result of having a mentally ill member. Assessment data best support this diagnosis. Data are insufficient to support the other diagnoses.

23. A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

ANS: D A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors. 24. Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements* ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

8. A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."

ANS: D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion.

24. A troubled adolescent pulled out a gun in a school cafeteria, fatally shot three people and injured many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next? a. Ask police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

ANS: D Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

ANS: D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

6. While performing an assessment, the nurse says to a patient, "While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?" The purpose of this question is to a. identify areas of sexual dysfunction for treatment. b. determine possible homosexual urges. c. introduce the topic of masturbation. d. identify sexual misinformation.

ANS: D Misinformation about normal sex and sexuality is common. Lack of knowledge may affect an individual's sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.

6. An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

17. Which scenario is an example of a situational crisis? a. The death of a child from sudden infant death syndrome b. Development of a heroin addiction c. Retirement of a 55-year-old person d. A riot at a rock concert

ANS: D The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of maturational crises.

8. The male manager of a health club placed a hidden video camera in the women's locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is a. homosexuality. b. exhibitionism. c. pedophilia. d. voyeurism.

ANS: D Voyeurism is achieving sexual pleasure through the viewing of others in intimate situations, such as undressing, bathing, or having sexual relations. A homosexual individual would be interested in watching members of the same sex, and homosexuality is not typically associated with voyeurism. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with children.

A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results were normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Conversion (functional neurological) disorder b. Illness anxiety disorder (hypochondriasis) c. Somatic symptom disorder d. Factitious disorder

B Patients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder.

A patient says, "I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your belief." b. "Let's see if there are any other possible explanations for your vomiting." c. "You seem so worried. Let's talk about how you're feeling." d. "We need to talk about something else."

B Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

A patient with blindness related to conversion (functional neurological) disorder says, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

B The patient mentions that the symptoms make people more interested. This indicates that the patient feels uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario.

A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply. a. Increase private visiting time for the parents to improve bonding. b. Keep careful, detailed records of visitation and untoward events. c. Place mittens on the child to reduce access to ports and incisions. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.

B, D, E Factitious disorder by proxy is a rare condition wherein a person intentionally causes or perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with fecal material). When this disorder is suspected, the child's life could be at risk. Depending on the evidence supporting this suspicion, interventions could range from minimizing unsupervised visitation to blocking visitation altogether. Frequently checking on the child during visitation and minimizing unobserved access to the child (by encouraging small group visits) reduces the opportunity to take harmful action and increases the collection of data that can help determine whether this disorder is at the root of the child's illness.

To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. are generally chronic. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.

D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide secondary gain, patients frequently fiercely cling to the symptoms. The symptoms tend to be chronic, but that does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) a.Obsessive-compulsive b.Antisocial c.Borderline d. Schizotypal e.Narcissistic

OCD, antisocial, Borderline, schizotypical

he history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by a.adherence to a strict moral code. b.manipulative, controlling strategies. c.acting without thought on urges or desires. d.postponing gratification to an appropriate time.

acting without thought on urges or desires

One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should a.arrange for emergency inpatient hospitalization. b.send the patient to the crisis intervention unit for 8 to 12 hours. c.assist the patient to choose coping strategies for triggering situations. d.advise the patient to take an antianxiety medication to decrease the anxiety level.

assist the patient to choose coping strategies for triggering situations

As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a.Reinforce this assertive action by the patient. Leave the medication on the table as requested. b.Respond to the patient, "I'm worried that you might not take it. I'll come back later." c.Say to the patient, "I must watch you take the medication. Please take it now." d.Ask the patient, "Why don't you want to take your medication now?"

say to the patient, i must watch you take the medication. please take it now

A patient diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The patient remains impulsive. Which nursing diagnosis is the initial focus of this patient's care? a.Self-mutilation b.Impaired skin integrity c.Risk for injury d.Powerlessness

self mutilation

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as a.denial. b.splitting. c.defensive. d.reaction formation.

splitting

25. An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem.

4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who a. have been abused. b. are attention seeking. c. have eating disorders. d. are developmentally delayed.

ANS: A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.

5. While conducting the initial interview with a patient in crisis, the nurse should a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know the nurse controls the interview.

ANS: A Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is nontherapeutic.

15. A victim of intimate partner violence comes to the crisis center seeking help. Crisis intervention strategies the nurse applies will focus on a. supporting emotional security and reestablishing equilibrium. b. long-term resolution of issues precipitating the crisis. c. promoting growth of the individual. d. providing legal assistance.

ANS: A Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the precrisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable.

21. A man who regularly experiences premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner." Select the nurse's most therapeutic response. a. "I sense you are feeling frustrated and upset." b. "Tell me more about feeling like a failure." c. "You are too hard on yourself." d. "What do you mean by awful?"

ANS: A Using reflection and empathy promotes trust and conveys concern to the patient. The distracters do not offer empathy, probe, and offer premature reassurance.

11. A parent is admitted to a unit for treatment of addictions. The patient's spouse and adolescent children attend a family session. Which initial assessment question should the nurse ask of family members? a. "What changes are most important to you?" b. "How are feelings expressed in your family?" c. "What types of family education would benefit your family?" d. "Can you identify a long-term goal for improved functioning?"

ANS: B It is important to understand family characteristics, particularly in a family under stress. Expression of feelings is an important aspect of assessment of the family's function (or dysfunction). The distracters relate more to outcome identification and planning interventions, both of which should be delayed until the assessment is complete.

1. A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

ANS: B Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

19. Which scenario best illustrates scapegoating within a family? a. The identified patient sends messages of aggression to selected family members. b. Family members project problems of the family onto one particular family member. c. The identified patient threatens separation from the family to induce feelings of isolation and despair. d. Family members give the identified patient nonverbal messages that conflict with verbal messages.

ANS: B Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the members of the family.

1. An adult outpatient diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in the event of another overdose of prescribed medication.

13. Two divorced people plan to marry. The man has a teenager, and the woman has a toddler. This family will benefit most from a. role-playing opportunities for conflict resolution regarding discipline. b. guidance about parenting children at two developmental levels. c. formal teaching about problem-solving skills. d. referral to a family therapist.

ANS: B The newly formed family will be coping with tasks associated with the stage of rearing preschool children and teenagers. These stages require different knowledge and skills. There is no evidence of a problem, so the distracters are not indicated.

16. A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should a. say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information about physical and emotional reactions the person may experience. c. explain the need and importance of infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.

7. A person says, "I often feel like I have been dreaming just before I awake in the morning." Which rationale correctly explains the comment? a. Sleep architecture changes during the sleep period, resulting in increased slow-wave sleep at the end of the cycle. b. Cycles of REM sleep increase in the second half of sleep and occupy longer periods. c. Dreams occur more frequently when a person is experiencing unresolved conflicts or depression. d. Dream content relates directly to developmental tasks. The person is likely feeling autonomous.

ANS: B Cycles of REM sleep increase in the second half of sleep and occupy longer periods, up to 1 hour. Dreaming occurs during REM sleep. The question relates to sleep architecture rather than dream content.

5. A patient needs diagnostic evaluation of sleep problems. Which test will evaluate the patient for possible sleep-related problems? a. Skull x-rays b. Electroencephalogram (EEG) c. Positron emission tomography (PET) d. Single photon emission computed tomography (SPECT)

ANS: B EEG measures nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. The distracters represent ways to diagnose structural and metabolic problems.

18. A nurse who works night shift says, "I am exhausted most of the time. I sleep through my alarm. Sometimes my brain does not seem to work right. I am worried that I might make a practice error." Which question should the nursing supervisor ask first? a. "What stress are you experiencing in your life?" b. "How much sleep do you get in a 24-hour period?" c. "Would it help if you do some exercises just before going to bed?" d. "Have you considered using a hypnotic medication to help you sleep?"

ANS: B Total sleep hours should be ascertained before seeking to correct a sleep disorder. In this case, the patient describes sleep deprivation symptoms rather than a sleep disorder. The correct response is the only option that addresses total sleep hours.

23. A patient in a detoxification unit asks, "What good it will do to go to Alcoholics Anonymous and talk to other people with the same problem?" The nurse's best response would be to explain that self-help groups such as AA provide opportunities for a. newly discharged alcoholics to learn about the disease of alcoholism. b. people with common problems to share their experiences with alcoholism and recovery. c. patients with alcoholism to receive insight-oriented treatment about the etiology of their disease. d. professional counselors to provide guidance to individuals recovering from alcoholism.

ANS: B The patient needs basic information about the purpose of a self-help group. The basis of self-help groups is sharing by individuals with similar problems. Self-help is based on the belief that an individual with a problem can be truly understood and helped only by others who have the same problem. The other options fail to address this or provide incorrect information.

5. A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.

ANS: B, D As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue.

2. A leader begins the discussion at the first meeting of a new group. Which comments should be included? (Select all that apply.) a. "We use groups to provide treatment because it's a more cost-effective use of staff in this time of budget constraints." b. "When someone shares a personal experience, it's important to keep the information confidential." c. "Talking to family members about our group discussions will help us achieve our goals." d. "Everyone is expected to share a personal experience at each group meeting." e. "It is important for everyone to arrive on time for our group."

ANS: B, E The leader must set ground rules for the group before members can effectively participate. Confidentiality of personal experiences should be maintained. Arriving on time is important to the group process. Talking to family members would jeopardize confidentiality. While groups are cost-effective, blaming the budget would not help members feel valued. Setting an expectation to share may be intimidating for a withdrawn patient.

29. A nurse gives anticipatory guidance to the family of a patient diagnosed with mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C Families should be made aware that the patient will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms are usually seen at later stages of the disease.

2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

12. Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? a. Homosexual b. Ritualistic behaviors c. Seeks access to children d. Self-confident professional

ANS: C Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder.

1. A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? a. "I will call your care provider. Perhaps you need a different medication." b. "Don't worry. You can try taking it at a different time of day to help it work better." c. "It usually takes a few weeks for you to notice improvement from this medication." d. "Your life is much better now. You will feel better soon."

ANS: C Seeing a response to antidepressants takes 3 to 6 weeks. No change in medications is indicated at this point of treatment because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that their life is better does not acknowledge their feelings.

10. A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."

ANS: C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.

4. A nurse provides health education for an adult with sleep deprivation. It is most important for the nurse to encourage caution when the patient engages in a. using a vacuum cleaner. b. cooking a meal. c. driving a car. d. bathing.

ANS: C Safety is the highest priority for this patient. Sleep deprivation causes psychomotor deficits. Driver drowsiness and fatigue lead to many automobile injuries and fatalities. The distracters are less likely to be associated with serious injury.

4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

ANS: C Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

18. Select the best question for the nurse to ask to assess a family's ability to cope. a. "What strengths does your family have?" b. "Do you think your family copes effectively?" c. "Describe how you successfully handled one family problem." d. "How do you think the current family problem should be resolved?"

ANS: C The correct option is the only statement addressing coping strategies used by the family. The distracters seek opinions or use closed-ended communication techniques.

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

ANS: C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving.

2. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

3. Which important points should the nurse teach a patient about using herbal preparations? (Select all that apply.) a. Check active and inactive ingredients. b. Discontinue use if side or adverse effects occur. c. Avoid herbals during pregnancy and breast-feeding. d. Buying from online sources is preferable and cheaper. e. Inform your health care provider about the use of herbals.

ANS: A, B, C, E All of the instruction is correct except regarding purchase of herbals. Herbals should be purchased from a reputable firm. Internet purchasing might not be the best plan, unless the reputation of the firm can be confirmed.

3. The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

ANS: A, B, C, E, F These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors are expected in obsessive-compulsive disorder.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a.Refer requests and questions related to care to the case manager. b.Encourage the patient to discuss feelings of fear and inferiority. c.Provide negative reinforcement for acting-out behavior. d.Ignore, rather than confront, inappropriate behavior.

refer requests and questions related to care to the case manager

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) a.Reclusive behavior b.Callous attitude c.Perfectionism d.Aggression e.Clinginess f.Anxiety

callous attitude, aggression

What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a.Respect the patient's need for periods of social isolation. b.Prevent the patient from violating the nurse's rights. c.Teach the patient how to select clothing for outings. d.Engage the patient in community activities.

respect the patients need for periods of social isolation

When a patient diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a.It provides an outlet for feelings of anger and frustration. b.It respects the patient's wishes, so assertiveness will develop. c.External controls are necessary due to failure of internal control. d.Anxiety is reduced when staff assumes responsibility for the patient's behavior.

external controls are necessary due to failure of internal control

A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a.Benzodiazepine b.Mood stabilizing medication c.Monoamine oxidase inhibitor (MAOI) d.Cholinesterase inhibitor

mood stabilizing medication

Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a. Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains

B Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the patient with conversion (functional neurological) disorder often exhibits less concern with the symptom they are presenting than would be expected. Neither disorder involves voluntary control of the symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological basis would be found for the symptoms). Secondary gains can occur in both disorders but are not necessary to either. See relationship to audience response question.

A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably: a. readily seek psychiatric counseling. b. be resistant to accepting psychiatric help. c. attend psychotherapy sessions without encouragement. d. be eager to discover the true reasons for physical symptoms.

B Patients with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these patients reject both.

A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? a. The patient is suppressing accurate feelings regarding the problem. b. The patient's anxiety is relieved through the physical symptom. c. The patient's optic nerve transmission has been impaired. d. The patient will not disclose genuine fears.

B Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously). See relationship to audience response question.

A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)

D Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others. See relationship to audience response question.

A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient: a. sees a relationship between symptoms and interpersonal conflicts. b. has little difficulty communicating emotional needs to others. c. rarely derives personal benefit from the symptoms. d. has altered comfort and activity needs.

D The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic symptom disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

A Patients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed "la belle indifférence." There is also a specific, identifiable cause for the development of the symptoms; in this instance, the death of a parent would precipitate stress. The distracters relate to sexual dysfunction and illness anxiety disorder.

Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"

A Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient's dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains.

A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that you are not satisfied with the care you are receiving." c. "Let's talk about why you use your call light so frequently. It is a problem." d. "You frustrate the staff by calling them so often. Why are you doing that?"

A This patient is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. "I'm wondering if you are anxious..." focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse's willingness to listen to the patient's feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the patient with her emotional needs.

A nurse's neighbor says, "I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?" The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including: (select all that apply) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

A, C, D, E A number of diseases can be worsened or brought to awareness by intense emotional stress. Immune disorders can be complicated associated with detrimental effects of stress on the immune system. Others can be brought about indirectly, such as cardiovascular disease due to acute or chronic hypertension. Hip fractures are not in this group.

6. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

1. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

28. An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

11. A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

14. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

26. A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

20. Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious patient will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a patient with sensorium problems related to delirium.

21. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

ANS: A The patient with moderately severe dementia has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the patient to a urinary tract infection

20. A patient in a support group says, "I'm tired of being sick. Everyone always helps me, but I will be glad when I can help someone else." This statement reflects a. altruism. b. universality. c. cohesiveness. d. corrective recapitulation.

ANS: A Altruism refers to the experience of being helpful or useful to others, a condition that the patient anticipates will happen. The other options are also therapeutic factors identified by Yalom.

14. A therapy group adds new members as others leave. What type of group is evident? a. Open b. Closed c. Homogeneous d. Heterogeneous

ANS: A An open group is a group that adds members throughout the life of the group as other members leave and as more persons who would benefit from the group become available. A closed group does not add new members; the membership is established at the beginning and, except for the occasional losses as some members leave, does not change thereafter. A homogeneous group includes members who are similar, and a heterogeneous group includes dissimilar members; not enough data are provided here to determine which applies in this case.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

7. As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? a. Assess for depression and ask directly about suicide thoughts. b. Ask the care provider to prescribe blood lab work to assess for depression. c. Focus on the presenting problems and refer the patient for a mental health evaluation. d. Interview the patient's family to identify their concerns about the patient's behaviors.

ANS: A Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.

25. Relaxation techniques help patients who have experienced major traumas because they a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

ANS: A In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.

2. A leader plans to start a new self-esteem building group. Which intervention would be most helpful for assuring mutual respect within the group? a. Describe the importance of mutual respect in the first session and establish it as a group norm. b. Exclude potential members whose behavior suggests they are likely to be disrespectful of others. c. Give members a brochure describing the purpose, norms, and expectations of the group. d. Explain that mutual respect is expected and confront those who are not respectful.

ANS: A It is helpful to motivate members to behave respectfully by describing how mutual respect benefits all members and is necessary for the group to be fully therapeutic. Setting a tone and expectation of mutual respect from the outset is the most helpful intervention listed. Excluding members because of how they might behave could exclude members who would have been appropriate, depriving them of the potential benefits of the group. Conveying expectations by brochure is less effective than doing so orally, because it lacks the connection to each member a skilled leader can create to motivate members and impart the expectation of respect. Confronting inappropriate behavior is therapeutic but only addresses existing behavior rather than preventing all such undesired behavior.

23. Which comment by a mother during a family therapy session shows evidence of scapegoating? a. "Our youngest child always starts arguments and upsets everyone else." b. "We all express our feelings openly except when we think it might upset my husband." c. "Our oldest child knows that my husband and I are doing all we can for the others." d. "After my husband has been drinking, I have to get everyone up and ready for school."

ANS: A Scapegoating is blaming family problems on a member of the family who is not very powerful. The purpose of the blaming is to keep the focus off painful issues and off the blamers themselves. A double-bind message, such as "We all express our feelings openly except when," involves giving instructions that are inherently contradictory or that place the person in a no-win situation. "Our oldest child knows that ..." is an example of triangulation, wherein a third party is engaged to help stabilize an unstable pair within the family. A child assuming parental responsibilities (e.g., caring for siblings) because a parent fails to do so is an example of enabling.

20. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: A Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.

9. A patient has talked constantly throughout the group therapy session, often repeating the same comments. Other members were initially attentive then became bored, inattentive, and finally sullen. Which comment by the nurse leader would be most effective? a. Say to everyone, "Most of you have become quiet. I wonder if it might be related to concerns you may have about how the group is progressing today." b. Say to everyone, "One person has done most of the talking. I think it would be helpful for everyone to say how that has affected your experience of the group." c. Say to everyone, "I noticed that as our group progressed, most members became quiet, then disinterested, and now seem almost angry. What is going on?" d. Say to the talkative patient, "You have been doing most of the talking, and others have not had a chance to speak as a result. Could you please yield to others now?"

ANS: A The most effective action the nurse leader can take will be the one that encourages the group to solve its own problem. Pointing out changes in the group and asking members to respond to them lays the foundation for a discussion of group dynamics. Asking members to respond to the talkative patient puts that patient in an awkward position, likely increasing her anxiety. As anxiety increases, monopolizing behavior tends to increase as well, so this response would be self-defeating. Asking members what is going on is a broader opening and might lead to responses unrelated to the issue that bears addressing; narrowing the focus to the group process more directly addresses what is occurring in the group. Focusing on the talkative patient would be less effective and involves the leader addressing the issue instead of members first attempting to do so themselves (giving them a chance to practice skills such as assertive communication).

5. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

ANS: A The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

18. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

8. Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

ANS: A The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from one's body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are "lost" to the patient (blackouts).

11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

24. After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which physiological response would be expected for this patient? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited.

ANS: A The scenario presents chronic and potentially debilitating stress. The helpless and out of control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses initially result in rapid heart rate and respiration. After many hours, days, or months the body cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous system. This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure. Individuals with dissociative disorders have altered communication between higher and lower brain structures due to the massive release of endogenous opioids at the time of severe threat.

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that, or any other, medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient's right and may be appropriate. The other incorrect options do not feature violation of another's rights.

7. A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

ANS: A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of nontherapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.

26. Emergency response workers arrive in a community after a large-scale natural disaster. What is the workers' first action? a. Report to the incident command system (ICS) center. b. Determine whether the community is safe. c. Establish teams of workers with varied skills. d. Evaluate actions completed by local law enforcement.

ANS: A An ICS provides a common organizational structure facilitating an immediate response. It establishes a clear chain of command that supports the coordination of personnel and equipment at an event site. The incorrect responses describe actions that may or may not be taken by the ICS.

19. A patient reports, "The medicine prescribed to help me get to sleep worked well for about a month, but I don't have any more of those pills. Now my insomnia is worse than ever. I had nightmares the last 2 nights." Which type of medication did the health care provider most likely prescribe? a. Benzodiazepine b. Tricyclic antidepressant c. Conventional antipsychotic d. Central nervous system (CNS) stimulant

ANS: A Benzodiazepines, members of the hypnotic's family of medications, can worsen existing sleep disturbances when they are discontinued. This class of medications produces tolerance. Once the drug is discontinued, the individual may have rebound insomnia and nightmares. CNS stimulants worsen insomnia while they are in use. Tricyclic antidepressants and atypical antipsychotics may help insomnia but would not be used for initial therapy.

10. A patient asks, "What is the major difference between conventional health care and complementary and alternative medicine (CAM)?" The nurse's best reply is that conventional health care a. focuses on what is done to the patient, whereas CAM focuses on body-mind interaction with an actively involved patient. b. has been tested by research so less regulation is needed, but CAM is religiously based and highly regulated. c. is controlled by the health care industry, but CAM is the people's medicine and not motivated by profit. d. is holistic and focused on health promotion, whereas CAM treats illnesses and is symptom-specific.

ANS: A Conventional health care focuses primarily on curative actions implemented on a mostly passive patient, whereas CAM focuses more on the mind-body aspects of health, along with the active involvement of the patient. Conventional health care is largely grounded in scientific research, and its various components are heavily regulated; the opposite tends to be true of CAM. Some forms of CAM have their roots in religious or cultural practices, but this is not characteristic of CAM as a whole. Both conventional health care and CAM can focus on health promotion and treatment of illness. Although critics express concern about the role of profit in conventional health care, the profit motive can also apply in CAM.

13. A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient's sexual practices? a. "Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?" b. "Sexual health can reflect a number of medical problems, so I'd like to ask if you have any sexual problems you think we should know about." c. "It's your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?" d. "I would appreciate it if you could share your sexual history with me so I can share it with your healthcare provider. It might be helpful in planning your treatment."

ANS: A Explaining that sexual practices vary helps reduce patient anxiety about the topic by normalizing the full range of sexual practices so that whatever his situation, the patient can feel comfortable sharing it. "It's your business of course ..." implies the nurse does not have a valid reason to seek the information and in effect suggests that the patient perhaps should not answer the question. "It might be helpful ..." makes the information seem less valid or important for the nurse to pursue and, again, could discourage the patient from responding fully. Asking if the patient has any sexual problems that staff should know about is not unprofessional, but it is a very broad question that may increase a patient's uncertainty about what the nurse wants to hear, thus increasing his anxiety. Defining or giving an example of "sexual problem" would make this inquiry more effective.

13. For which patient would it be most important for the nurse to urge immediate discontinuation of kava? A patient with a comorbid diagnosis of a. cirrhosis. b. osteoarthritis. c. multiple sclerosis. d. chronic back pain.

ANS: A Kava should be used with caution in patients with liver disease because of its potentially hepatotoxic effects. The other health problems do not pose immediate dangers.

26. The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a patient diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The patient's history of poly-substance abuse b. The patient's preference for homeopathic remedies c. The patient's family history of autoimmune disorders d. The patient's comorbid diagnosis of a learning disability

ANS: A Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The patient with a history of substance abuse is at risk to abuse this medication as well. The patient's preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant.

6. A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arm's length distance from the patient. d. begin talking to the patient about appropriate behavior.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

18. An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult a. consistently avoids schools and shops at malls only during school hours. b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.

ANS: A One strategy for avoiding acting on inappropriate urges is to avoid environments and circumstances that evoke those urges; for a pedophile this would include avoiding all situations that would likely result in contact with children. Pedophilic disorder is persistent; elimination of fantasies about children would be unrealistic. A person who volunteers to lead a scout troop is placing himself/herself around children. A diminished sex drive or a healthy sex life with an appropriate partner does not necessarily reduce the desire for sexual contact with children.

3. An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, "I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough." Which nursing diagnosis applies? a. Deficient knowledge related to faulty perception of health status b. Disturbed self-concept related to required lifestyle changes c. Disturbed body image related to treatment side effects d. Sexual dysfunction related to self-esteem disturbance

ANS: A Patients who have had a myocardial infarction often believe sexual intercourse will cause another heart attack. The patient has completed the rehabilitation, but education is needed regarding sexual activity. These patients should receive information about when sexual activity may begin, positions that conserve energy, and so forth. The scenario does not suggest self-concept or body image disturbance.

27. A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and reswallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia.

ANS: A Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in a child. Rumination refers to regurgitation with rechewing, reswallowing, or spitting.

20. Physical assessment of a patient diagnosed with bulimia often reveals a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

20. A patient experiencing primary insomnia asks the nurse, "I take a nap during the day. Doesn't that make up for a lost night's sleep?" Select the nurse's best reply. a. "Circadian drives give daytime naps a structure different from nighttime sleep." b. "The body clock operates on a 24-hour cycle, making nap effectiveness unpredictable." c. "It is a matter of habit and expectation. We expect to be more refreshed from a night's sleep." d. "Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night."

ANS: A Regular sleep cycles occur with nighttime sleep, with progression through two distinct physiological states: four stages of NREM and a period of REM sleep. Naps often contain different amounts of REM sleep, thus changing the physiology of sleep as well as the psychological and behavioral effects of sleep.

8. A patient diagnosed with major depressive disorder tells the nurse, "I want to try supplementing my selective serotonin reuptake inhibitor (SSRI) with St. John's wort." Which action should the nurse take first? a. Advise the patient of the danger of serotonin syndrome. b. Suggest that aromatherapy may produce better results. c. Assess the patient for depression and risk for suicide. d. Suggest the patient decrease the antidepressant dose.

ANS: A Research has suggested that St. John's wort is a mild inhibitor of serotonin reuptake and could lead to serotonin syndrome; this risk is increased if the patient is taking other medications that increase serotonin activity. Assessing the depression would be a secondary intervention. Aromatherapy has not been shown to be an effective adjunct or treatment for depression. Although a dosage reduction in her SSRI medication might reduce the risk of serotonin syndrome, this intervention is not in the nurse's scope of practice.

2. A nurse is performing an assessment for a 59-year-old man with a long history of hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension. b. Such questions are an indirect way of learning about the patient's medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.

ANS: A Some of the drugs used to treat hypertension can interfere with normal sexual functioning and lead to sexual disorders. Hypertension itself can lead to acquired erectile dysfunction. It would not be appropriate or necessary to use such inquiries as a lead-in to other sexual health topics. Sexual dysfunction, while stressful, does not cause hypertension.

20. An adult has cared for a debilitated parent for 10 years. The health care provider recently recommended transfer of the parent to a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this adult's crisis will most closely relate to a. resolving the feelings associated with the threat to the person's self-concept. b. ability of the person to identify situational supports in the community. c. reliance on assistance from role models within the person's culture. d. mobilization of automatic relief behaviors by the person.

ANS: A The adult's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the parent's condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors include withdrawal or flight and will not be helpful. Automatic relief behaviors are part of the third phase of crisis.

8. An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents b. Deficient knowledge related to interpersonal skills with parents c. Disturbed personal identity related to negative self-evaluation d. Complicated grieving related to poor academic performance

ANS: A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements.

19. During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills? a. "In the past, how have you handled difficult or stressful situations?" b. "What would you like us to do to help you feel more relaxed?" c. "Tell me more about how it feels to be anxious and upset." d. "Can you describe your role in the marital relationship?"

ANS: A The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis.

1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

ANS: A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.

12. Normally, most people sleep at night. What is the physiological rationale? a. The master biological clock responds to darkness with sleep. b. Darkness stimulates histamine release, which promotes sleep. c. Cooler environmental temperatures stimulate retinal messages. d. Stimulation of the sympathetic nervous system promotes sleep.

ANS: A The master biological clock in the suprachiasmatic nucleus (SCN) of the hypothalamus regulates sleep as well as other physiological processes. Darkness cues the clock for sleep. Light cues it for wakefulness. Light stimulates retinal messages. Histamine release is associated with wakefulness. Stimulation of the sympathetic nervous system promotes alertness.

7. A patient reports good results from taking an herb to manage migraine headache pain. The nurse confirms there are no hazardous interactions between the herb and the patient's current prescription drugs. Select the nurse's best comment to the patient. a. "Thanks for telling me. I'll make a note in your medical record that you take it." b. "You are experiencing a placebo effect. When we believe something will help, it usually does." c. "Self-management of health problems can be dangerous. You should have notified me sooner." d. "Research studies show that herbals actually increase migraine pain by inflaming nerve cells in the brain."

ANS: A The nurse should reinforce the patient for reporting use of the herb. Many patients keep secrets about use of alternative therapies. If it poses no danger, the nurse can document the use. The patient may also get placebo effect from the herb, but it is not necessary for the nurse to point out that information. The distracters are judgmental and may discourage the patient from openly sharing in the future.

15. A parent who is very concerned about a 3-year-old son says, "He likes to play with girls' toys. Do you think he is homosexual or mentally ill?" Which response by the nurse most professionally describes the current understanding of gender identity? a. "A child's interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood." b. "It's difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult." c. "The research is incomplete, but many boys play with girls' toys and turn out normal as adults." d. "I am sure that whatever happens, he will be a loving son, and you will be a proud parent."

ANS: A The parent's inquiry is representing two questions: (1) whether the child's behavior suggests an increased risk of developing mental illness and (2) what the child's future sexual preference will be. The psychiatric disorder that most directly addresses gender preferences and cross-gender activities is gender identity disorder. Pointing out that cross-gender activities are not necessarily related to gender identity and not likely to be carried into adulthood is supported by current research. Saying the child will grow up to be "normal" implies that to be homosexual is to be abnormal, which reflects a cultural perspective that most professionals would believe to be inappropriate to share in a professional setting. Research provides information about the relationship between cross-gender interests in childhood and adulthood, so a comment that "research is incomplete" is not entirely accurate. Stating that the child is a wonderful boy the father will be proud of, whatever happens, evades the parent's question and suggests that parental bonds should not be affected by gender issues. The nurse has a professional obligation to maintain an objective, therapeutic relationship.

17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.

18. A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response. a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."

ANS: A The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

12. A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.

ANS: A The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.

15. A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage

ANS: A The victim's response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.

4. A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds' overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? (Select all that apply.) a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patient's eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? (Select all that apply.) a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever spank your children?" e. "Calling children 'stupid' injures their self-esteem."

ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

1. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? (Select all that apply.) a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.

2. A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.) a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence.

2. A parent was recently hospitalized with severe depression. Family members say, "We're falling apart. Nobody knows what to expect, who should make decisions, or how to keep the family together." Which interventions should the nurse use when working with this family? (Select all that apply.) a. Help the family set realistic expectations. b. Provide empathy, acceptance, and support. c. Empower the family by teaching problem solving. d. Negotiate role flexibility among family members. e. Focus planning on the family rather than on the patient.

ANS: A, B, C, D The correct answers address expressed needs of the family. The distracter is inappropriate.

1. A patient in good health and without any major health needs says, "I want to try some techniques to improve my mental and physical well-being but I'm overwhelmed by all the suggestions on the Internet." Which techniques would be appropriate for the nurse to suggest? (Select all that apply.) a. Yoga b. Exercise c. Meditation d. Aromatherapy e. Acupuncture f. Spinal manipulation

ANS: A, B, C, D Yoga, exercise, meditation, and aromatherapy are self-help techniques that may have a positive effect on the patient's physical and mental well-being. These techniques are unlikely to cause harm. The patient is in good health; therefore, acupuncture and spinal manipulation are not indicated.

2. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.

ANS: A, B, C, E The child's symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.

1. A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (provides information if the patient has agnosia). When a patient resists, it is appropriate to use distraction and try again after a short interval because patient moods are often labile. The patient may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

2. A patient who emigrated from India is hospitalized. The patient and family use ayurvedic medicine. The nurse wants to adjust this patient's care so that it is more comfortable and familiar. What changes from usual Western practice should be considered? (Select all that apply.) a. In preparation for discharge, include a significant focus on preventive practices. b. Spend time exploring the patient's life overall, focusing on broader issues than health. c. Involve the patient's entire family and treatment team in decisions about treatment options. d. Anticipate that the patient will prefer and value interventions with high technology features. e. Provide relevant health-related information and then encourage the patient to determine which course of action to pursue.

ANS: A, B, E Ayurvedic medicine, an ancient practice that originated in India, stresses individual responsibility for health, is holistic, promotes prevention, recognizes the uniqueness of the individual, and offers natural methods of treatment. Ayurvedic medicine does not require spiritual cleansing or the involvement of family and the treatment team in all decisions.

1. A nurse assesses a patient diagnosed with a paraphilic disorder. Which findings are most likely? (Select all that apply.) a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity

ANS: A, C, D ADHD in childhood, substance abuse, phobic disorders, and major depressive disorder/dysthymia are strongly associated with paraphilic disorders. Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur. Patients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self-confidence is lacking; therefore, grandiosity would not be expected.

6. Which scenarios describe completed rape? (Select all that apply.) a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.

ANS: A, C, D The correct responses depict scenarios of completed rape. The incorrect responses represent consensual sexual contact and sexual assault. Consensual sex is not considered rape if the participants are of legal age.

4. Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.) a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.

1. When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected.

3. A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.) a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

1. A wife believes her husband is having an affair. Lately, he has been disinterested in romance and working late. The husband has an important, demanding project at work. The mother asks her teen, "What have you noticed about your father?" The teen later mentions this to the father, who says, "Tell your mother that I can't deal with her insecurities right now." Family therapy should focus on (Select all that apply.) a. identifying and reducing the cognitive distortion in each parent's perceptions. b. confronting the family with the need for honest, direct, assertive communication. c. helping the parents find ways to cope more effectively with their stress and fears. d. supporting the teen to redirect the parents when they try to communicate through her. e. convincing the mother that her fear of an affair is due to her own insecurities and unfounded. f. helping the husband understand how others might misinterpret the changes in his behavior.

ANS: A, C, D, F Each parent is seeing the other's behavior in a possibly distorted manner, which the nurse would explore and help the parents correct. The nurse would guide the parents to communicate more effectively, but confrontation would likely be non-therapeutic because it would increase the tension and triangulation. Since fear and anxiety contribute to triangulation, increasing the parent's coping abilities as well as reducing anxiety and fear would be areas for intervention. Teaching the adolescent how to protect herself from triangulation, when done in conjunction with interventions to help the parents reduce this behavior, would be protective of the adolescent and would assist the parents in their efforts to change this pattern of communication. The nurse has no facts about whether or not the husband is having an affair; therefore, the nurse should not convince the wife that her fear is only due to her insecurities. Her fears may be well-founded. Helping the husband understand how his wife might see the changes in behavior differently can help him to respond helpfully instead of accusing her of being insecure.

1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

2. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.) a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

ANS: A, C, E Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

4. Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.) a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

1. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? (Select all that apply.) a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

ANS: A, D, E Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

1. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.) a. Stating the expectation that the patient will stay in control. b. Asking the patient, "Do you want to go into seclusion?" c. Telling the patient, "You are behaving inappropriately." d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

3. Which central nervous system structures are most associated with anger and aggression? (Select all that apply.) a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Prefrontal cortex

ANS: A, D, E The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

4. Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms, the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

ANS: A, D, E The nurse assesses the victim's level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance.

18. During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

13. A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

19. A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. The patient will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the patient's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the patient leaves the home, but it does not prevent wandering or assure the patient's safety.

23. A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficit and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because patients with dementia sometimes become more agitated with reorientation.

19. A group has two more sessions before it ends. One member was previously vocal and has shown much progress but has now grown silent. What explanation most likely underlies this behavior? The silent member a. has participated in the group and now has nothing more to offer. b. is having trouble dealing with feelings about termination of this group. c. wants to give quieter members a chance to talk in the remaining sessions. d. is engaging in attention-seeking behavior aimed at continuation of the group.

ANS: B A chief task during the termination phase of a group is to take what has been learned in group and transition to life without the group. The end of a group can be a significant loss for members, who may experience loss and grief and respond with sadness or anger. It is unlikely he would have nothing to say; at the very least, he could be responding to the comments of others even if not focusing on his own issues. He may wish to give quieter members a chance to talk, but again, this would not require or explain his complete silence. Some members, faced with only two remaining sessions, may be becoming more dominant under this pressure of time, but here too this is unlikely to lead a previously active participant to fall completely silent. The member is not attention-seeking.

3. After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

ANS: B Adjustment disorders may be associated with grief. A statement that validates a bereaved person's loss is more helpful than false reassurances and clichés. It signifies understanding.

24. Which type of group is a staff nurse with 2 months' psychiatric experience best qualified to conduct? a. Psychodynamic/psychoanalytic group b. Medication education group c. Existential/Gestalt group d. Family therapy group

ANS: B All nurses receive information about patient teaching strategies and basic information about psychotropic medications, making a medication education group a logical group for a beginner to conduct. The other groups would need a leader with more education and experience.

21. During a support group, a patient diagnosed with schizophrenia says, "Sometimes I feel sad that I will never have a good job like my brother. Then I dwell on it and maybe I should not." Select the nurse leader's best comment to facilitate discussion of this issue. a. "It is often better to focus on our successes rather than our failures." b. "How have others in the group handled painful feelings like these?" c. "Grieving for what is lost is a normal part of having a mental disorder." d. "I wonder if you might also experience feelings of anger and helplessness."

ANS: B Asking others to share their experiences will facilitate discussion of an issue. Giving information may serve to close discussion of the issue because it sounds final. Suggesting a focus on the positives implies a discussion of the issue is not appropriate. Suggesting other possible feelings is inappropriate at this point, considering the patient has identified feelings of sadness and seems to have a desire to explore this feeling. Focusing on other feelings will derail discussion of the patient's grief for his perceived lost potential.

8. An adult diagnosed with schizophrenia lives with elderly parents. The patient was recently hospitalized with acute psychosis. One parent is very anxious, and the other is ill because of the stress. Which nursing diagnosis is most applicable to this scenario? a. Ineffective family coping related to parental role conflict b. Caregiver role strain related to the stress of chronic illness c. Impaired parenting related to patient's repeated hospitalizations d. Interrupted family processes related to relapse of acute psychosis

ANS: B Caregiver role strain refers to a caregiver's felt or exhibited difficulty in performing a family caregiver role. In this case, one parent exhibits stress-related illness and the other exhibits increased anxiety. The other nursing diagnoses are not substantiated by the information given and are incorrectly formatted (one nursing diagnosis should not be the etiology for another).

8. An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? a. There are no special preparations needed before this treatment. b. Common side effects include headache and short-term memory loss. c. One treatment will be needed to cure the depression. d. This treatment will leave you unconscious for several hours.

ANS: B Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.

9. An adult, recently diagnosed with AIDS, is hospitalized with pneumonia. The patient and family are very anxious. Select the best outcome to add to the plan of care for this family. a. Describe the stages of the anticipatory grieving process. b. Identify and describe effective methods for coping with anxiety. c. Recognize ways dysfunctional communication is expressed in the family. d. Examine previously unexpressed feelings related to the patient's sexuality.

ANS: B Desired outcomes might be set for the family as a whole or for individuals within the family. The outcome most closely associated with the anxiety that each member is experiencing is to focus on identifying and describing ways of coping with the anxiety. The other options are not appropriate at this time.

11. The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

ANS: B Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patient's time should not be loaded with demanding or stimulating activities.

24. A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

12. A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a prn dose of antianxiety medication.

ANS: B Helping the patient apply a grounding technique, such as exercise, assists the patient to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the patient. It is not necessary to notify the health care provider.

22. Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

10. A parent is admitted to a unit for treatment of addictions. The patient's spouse and adolescent children participate in a family session. What is the most important aspect of this family's assessment? a. Spouse's codependent behaviors b. Interactions among family members c. Patient's reaction to the family's anger d. Children's responses to the family sessions

ANS: B Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are narrower in scope when compared with the correct option.

23. A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? a. Request the information technology manager to verify the patient's medical record is secure in the hospital information system. b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. c. Consult the hospital's legal department regarding potential consequences of the event. d. Document a report of a sentinel event in the patient's medical record.

ANS: B Support and an opportunity for staff to safely express feelings about the event should occur first. Interventions should help the staff come to terms with the loss and grow because of the incident. Identifying overlooked clues or faulty judgments will provide the groundwork for identifying changes needed in policies and procedures for future patients. Consulting the legal department is not an initial measure. A sentinel event report is not part of the medical record and can be prepared later. The other incorrect options will not control information or would result in unsafe care.

11. The nurse is planning a new sexuality group for patients. Which location would best enhance the effectiveness of this group? a. The hospital auditorium b. A small conference room c. A common area, such as a day room d. The corner of the music therapy room

ANS: B The conference room would provide a quiet, private area with few distractions, separate from other patient areas and effective for teaching and learning about a private topic. The auditorium is too large, and members' anxiety or lack of trust might lead them to spread out too far from each other, interfering with group process. The day room and the music therapy room are too busy and exposed, reducing privacy and increasing distractions.

12. A nurse interviews a homeless parent with two teenage children. To best assess the family's use of resources, the nurse should ask a. "Can you describe a problem your family has successfully resolved?" b. "What community agencies have you found helpful in the past?" c. "What aspect of being homeless is most frightening for you?" d. "Do you feel you have adequate resources to survive?"

ANS: B The correct option asks about use of resources in an open, direct fashion. It will give information about choices the family has made regarding use of resources in the community. The other questions do not address prior use of resources or focus on other aspects of coping.

19. Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used."

ANS: B The correct response demonstrates consistent nurturing, which is a vital component of building resilience in children. The incorrect responses are not necessarily unhealthy parenting behaviors, but they do not clearly demonstrate parental nurturing.

16. Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

ANS: B The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

5. A 15-year-old is hospitalized after a suicide attempt. This adolescent lives with the mother, stepfather, and several siblings. When performing a family assessment, the nurse must first determine a. how the family expresses and manages emotion. b. names and relationships of the family's members. c. the communication patterns between the patient and parents. d. the meaning that the patient's suicide attempt has for family members.

ANS: B The identity of the members of the family is the most fundamental information and should be obtained first. Without this, the nurse cannot fully process the other responses.

15. During a therapy group that uses existential/Gestalt theory, patients shared feelings that occurred at the time of their admission. After a brief silence, one member says, "Several people have described feeling angry. I would like to hear from members who had other feelings." Which group role is evident by this comment? a. Energizer b. Encourager c. Compromiser d. Self-confessor

ANS: B The member is filling the role of encourager by acknowledging those who have contributed and encouraging input from others. An energizer encourages the group to make decisions or take an action. The compromiser focuses on reducing or resolving conflict to preserve harmony. A self-confessor verbalizes feelings or observations unrelated to the group.

10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the patient's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient's safety. The information in the other questions may be important to ask but are not the most critical.

14. Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our hopes for our child's future are ruined. We probably won't ever have grandchildren." The nurse will use interventions to assist with a. denial. b. acceptance. c. acting out. d. manipulation.

ANS: B The parents comment suggests they are experiencing grief, a common reaction to having a family member diagnosed with mental illness. The grief stems from actual or potential losses, such as the family's ability to function, financial well-being, and altered future. Supporting the parents' acceptance of the patient's illness will enhance coping. Data do not support choosing any of the other options.

14. The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis

ANS: B The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or "mind flight" may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur.

25. A wife believes her husband is having an affair. Lately, he has been disinterested in romance and working late. The husband has an important, demanding project at work. The mother asks her teen, "What have you noticed about your father?" The teen later mentions this to the father, who says, "Tell your mother that I can't deal with her insecurities right now." Which family dynamic is evident? a. Multigenerational dysfunction b. Triangulation c. Enmeshment d. Blaming

ANS: B Triangulation is a family dynamic wherein a pair relationship (usually the parents) is under stress and copes by drawing in a third person (usually a child) to align with one or the other members of the pair relationship. Multigenerational dysfunction is any dysfunction that exists within or across multiple generations of a family, such as child abuse or alcoholism. Blaming is distracting attention from one's own dysfunction or reducing one's own anxiety by blaming another person. Enmeshment refers to blurred family boundaries or blending together of the thoughts, feelings, or family roles of the individuals so that clear distinctions among members fail to emerge.

1. A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. Choose the nurse's best initial comment to this patient. a. "Everything is going to be all right. You are here at the clinic and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying and pacing so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

ANS: B A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

2. Which comment is most likely from a patient with chronic sleep deprivation? a. "I turn on the television every night to get to sleep. I set the timer so it goes off in 30 minutes." b. "I have diarrhea frequently and not much energy, so I stay at home most of the time." c. "I only sleep about 7 hours a night, but I know I should sleep 8 or 9 hours." d. "When my alarm clock goes off every morning, it seems like I am dreaming."

ANS: B A discrepancy between hours of sleep obtained and hours required leads to sleep deprivation. Adults with less than 6 hours of sleep per night often suffer from chronic sleep deprivation. Common complaints include poor general health, physical and mental distress, limitations in ADLs, depressive or anxious symptoms, and pain. One distracter indicates a problem with sleep hygiene (television). The remaining distracters do not indicate a problem.

12. Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness

ANS: B A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

7. An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room a. and say, "Would you like to come to your room and take some medication your health care provider prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there."

ANS: B A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

8. A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

11. A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"

ANS: B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a nontherapeutic communication technique. The victim may or may not have friends who have had this experience, but it is important to talk about his feelings rather than theirs.

9. A patient tells the nurse, "I get sick so much, so I started taking ginseng to boost my immune system." The patient's only other medication is warfarin daily. Which potential complication should be included in the nursing assessment? a. Gastrointestinal distress b. Spontaneous bleeding c. Thromboembolism d. Drowsiness

ANS: B Ginseng may interact with anticoagulants and cause spontaneous bleeding. Warfarin is such an agent and can predispose the patient to spontaneous bleeding. It would not increase the risk of thromboembolism. Drowsiness and gastrointestinal complaints are common side effects.

19. A patient had a venous thrombosis 3 weeks ago and is now taking warfarin. When visiting the laboratory to have a prothrombin time drawn, the patient reports drinking ginseng tea to stimulate the immune system. Which nursing diagnosis applies? a. Impaired memory related to neurological changes b. Deficient knowledge related to potentially harmful drug interactions c. Ineffective denial related to consequences of mismanagement of therapeutic regime d. Effective management of the therapeutic regime related to augmentation of anti-coagulant therapy

ANS: B Ginseng tea is amongst the top 10 herbal products used in the United States and believed to have multiple beneficial properties. Because it antagonizes platelet-activating factor, it should not be taken by patients who are receiving anticoagulants or who have other potential bleeding problems. Thus, deficient knowledge is an appropriate nursing diagnosis.

18. A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

ANS: B Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting-out anger, and eventually to put into practice more adaptive coping strategies.

3. A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is a. suicidal. b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

ANS: B Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety.

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

ANS: B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

18. A patient report, "Last night I had several mixed drinks at a party. When I got home, I had difficulty falling sleep. I made two cups of herbal tea with lavender. This morning, I feel very groggy and have a headache." The nurse should explain that a. lavender should be delayed at least 1 hour after using alcohol to avoid side effects. b. lavender may increase sedation from other central nervous system depressants. c. herbal teas often cause nervous system side effects such as headaches. d. these feelings are actually a hangover from excessive alcohol intake.

ANS: B Lavender has sedative properties that are potentiated when used in combination with other central nervous system depressants. Headaches are another possible side effect of this herbal medicine. The nurse should advise caution in ingesting alcohol and lavender for these reasons. Taking lavender an hour after alcohol will not prevent these interactions, and it is likely that the lavender played a role in her feeling perhaps worse than usual after this episode of drinking. Herbal teas cause headaches in some cases, but it is not characteristic of this group of herbal remedies.

16. After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Body image

ANS: C Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual. "Reactive" and "body image" are not types of crisis.

5. A patient says, "I have taken mega doses of vitamins for 3 months to improve my circulation, but I think I feel worse." Which action should the nurse take first? a. Explain to the patient that vitamin mega doses may be harmful and advise caution. b. Assess the patient for symptoms and signs of toxicity from excess vitamin exposure. c. Assess for signs of circulatory integrity to determine whether improvement has occurred. d. Educate the patient that research has not shown that megadoses of vitamins produce benefits.

ANS: B Mega doses of many vitamins, especially when taken over long periods, may produce dangerous side effects or toxicity. The priority for the nurse is to assess for signs of any dangerous consequences of the patient's use of such a regimen. Secondary interventions would include patient education about research findings related to the practice, along with any benefits and undesired effects associated with the practice. A health care provider should also assess the patient for cardiovascular concerns.

17. A patient reports, "Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM." The nurse assesses this disorder as most consistent with criteria for which problem? a. Sleep deprivation b. Nightmare disorder c. Night terror disorder d. REM sleep behavior disorder

ANS: B Nightmares are long, frightening dreams from which people awaken in a frightened state. They occur during REM sleep late in the night. Night terror disorder occurs as arousal in the first third of the night during NREM sleep and is accompanied by feelings of panic. REM sleep behavior disorder involves acting out a violent dream during REM sleep. Nightmare disorder may lead to sleep deprivation.

7. A woman tells the nurse, "My partner is frustrated with me. I don't have any natural lubrication when we have sex." What type of sexual disorder is evident? a. Genito-pelvic pain/penetration disorder b. Female sexual interest/arousal disorder c. Hypoactive sexual desire disorder d. Female orgasmic disorder

ANS: B One feature of female sexual interest/arousal disorder relates to inability to maintain physiological requirements for intercourse. For women, this includes problems with lubrication and swelling. The patient's description does not meet criteria for diagnoses in the distracters.

11. An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.

ANS: B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

17. A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest? a. Determine the nature and extent of the coach's sexual disorder. b. Assess the coach's potential for suicide or other self-harm. c. Assess the coach's self-perception of problem and needs. d. Determine whether other children were harmed.

ANS: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims' families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patient's disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel. See relationship to audience response question.

3. After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias

ANS: B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.

6. A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

ANS: B Salty water is a slang/street name for GHB (-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1 to 12 hours, but the duration is less important than the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability.

14. A home care nurse assesses a very demanding patient with chronic obstructive pulmonary disease (COPD). Afterward, the nurse talks with the spouse who has provided this patient's care for 6 years. The spouse says, "I don't need much sleep anymore. I might need to help him during the night." Select the nurse's most therapeutic response. a. "It sounds like you are very devoted to your spouse." b. "I noticed you fell asleep while I was assessing your spouse. I'm concerned about you." c. "Your spouse is lucky to have you to provide care rather than being placed in a nursing home." d. "If you keep going like this, your health will be impaired also. Then who will take care of both of you?"

ANS: B Sleep deprivation can cause accidents. The correct answer makes an observation, gives important information about safety, and communicates care and compassion for the spouse. The distracters do not invite further dialogue with the spouse.

20. Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium b. Trazodone c. Olanzapine d. Valproic acid

ANS: C Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

13. A nurse counsels a patient on ways to determine the person's total sleep requirement. Which instruction would produce the most accurate results? a. "For 1 full week, record what you remember about your dream content and related feelings as soon as you wake up. Bring the record to your next appointment." b. "While off work for 1 week, go to bed at your usual time and wake up without an alarm. Record how many hours you sleep and then average the findings." c. "For 2 full weeks, record how much time you sleep each night and rate your daytime alertness on a scale of 1 to 10. Calculate your average alertness score." d. "All adults need 7 or 8 hours of sleep to function properly. Let's design ways to help you reach that goal."

ANS: B Sleep requirements are most accurately determined by going to bed at the usual time and waking up without an alarm for several nights, ideally on vacation. The average of these findings indicates the estimated requirements. Two distracters relate to dream content and daytime alertness. Some adults are long sleepers or short sleepers with different requirements for sleep from the general population.

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

ANS: B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to overinvolvement with victims rather than healthy transference.

1. A patient tells the nurse, "I've been having problems getting a good night's sleep. I read some information on the Internet and started taking kava kava." Select the nurse's priority response. a. "The Internet does not have reliable health information for consumers." b. "The Food and Drug Administration warned against using it due to the link to severe liver damage." c. "Melatonin has been shown to have better effects for treating sleep disturbances." d. "Your sleep disturbances are related to your problems with anxiety. Herbs will not help."

ANS: B The Food and Drug Administration (FDA) warned against using kava kava due to the link to severe liver damage. The nurse has responsibilities to educate patients regarding safe use of complementary therapies. Melatonin may be useful for sleep disturbances, but the patient's safety is a higher priority. The other distracters are misleading.

9. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman says tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, "You are a strong person. You can get through this crisis." d. foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of situational supports should continue. Even though the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

1. A new staff nurse tells the clinical nurse specialist, "I am unsure about my role when patients bring up sexual problems." The clinical nurse specialist should give clarification by saying, "All nurses a. qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle." b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths." c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality." d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples."

ANS: B The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors. Additional education is necessary. A registered nurse may provide basic information about sexual function, but complex questions may require referral.

1. A nurse cares for these four patients. Which patient has the highest risk for problems with sleep physiology? a. Retiree who volunteers twice a week at Habitat for Humanity b. Corporate accountant who travels frequently c. Parent with three teenagers d. Lawn care worker

ANS: B The corporate accountant is likely to work long hours and have significant stress associated with work demands. Compounded by travel, these factors are likely to precipitate unstable sleep patterns and inadequate sleep time. The retiree and lawn care worker engage in physical activity during the day, which will promote natural fatigue and sleep. The parent's sleep is unlikely to be disturbed; teenagers sleep through the night.

10. An adult patient assaulted another patient and was then restrained. One hour later, which NURSINGTB.COM statement by the restrained patient requires the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "The other patient started the fight."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

13. Which communication technique will the nurse use more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

ANS: B The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

7. Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

ANS: B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

23. An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Interrupted family processes

ANS: B The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's family processes are not interrupted at this point.

18. An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

ANS: B The patient's caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

12. An older male patient has suffered with episodic pruritus and skin eruptions for over 2 years. This patient tells the nurse, "When my skin gets better for a few days, I start worrying that it's going to start itching again soon. I think my worry may actually trigger the problems to start all over again." Which self-help technique should the nurse consider suggesting for this patient? a. Melatonin b. Meditation c. Purification d. Acupuncture

ANS: B The patient's comment suggests an element of anxiety accompanies the skin problem. Meditation is a popular self-help method recommended to reduce physical and emotional stress and to promote wellness. Purification, associated with ayurvedic practices, may or may not appeal to this patient. Acupuncture is performed by a professional practitioner, so it is not a self-help technique. The scenario does not indicate the patient is experiencing insomnia, so melatonin is not indicated.

9. A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of a. Paraphilic disorder. b. Female orgasmic disorder. c. Genito-pelvic pain/penetration disorder. d. Female sexual interest/arousal disorder.

ANS: B The persistent inhibition of orgasm is a form of sexual dysfunction called female orgasmic disorder. Genito-pelvic pain/penetration disorder applies to painful intercourse. The patient has not indicated that her interest in sexual activity is diminished, so female sexual interest/arousal disorder does not apply. Paraphilic disorder is not applicable.

22. A man who reports frequently experiencing premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner. Can you help me?" Select the nurse's best response. a. "Have you discussed this problem with your partner?" b. "I can refer you to a practitioner who can help you with this problem." c. "Have you asked your health care provider for prescription medication?" d. "There are several techniques described in this pamphlet that might be helpful."

ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurse's role.

17. A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, "I'm in pain all the time but you don't give me medicine until YOU think it's time." Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

ANS: B Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient's anxiety and anger. Dependency is not an important concern related to acute pain.

20. Select the best desired outcome for a patient who uses valerian. The patient will report a. stress level is lower. b. undisturbed sleep throughout the night. c. increased interest in recreational activities. d. early morning waking without an alarm clock.

ANS: B Valerian decreases sleep latency, nocturnal waking, and leads to a subjective sense of good sleep. Sleeping through the night is the best indicator the herb was effective. Although the patient's stress level may be lowered by use of valerian, the problem is insomnia; outcomes should relate to the problem. Early morning waking is indicative of depression or anxiety.

2. A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? (Select all that apply.) a. Preparedness b. Mitigation c. Response d. Recovery e. Evaluation

ANS: B, C This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

3. A new patient at the sleep disorders clinic tells the nurse, "I have not slept well in a year, so I never feel good. I do not expect things will ever improve or be any different." Interventions the nurse should consider include (Select all that apply) a. suggesting use of alcohol as a sedative. b. providing instruction in relaxation techniques. c. counseling the patient to address cognitive distortions. d. health teaching regarding factors that influence sleep. e. teaching fatigue-producing activities to become overtired. f. encouraging long daytime naps to compensate for sleep deprivation.

ANS: B, C, D Interventions that could be helpful include teaching relaxation techniques, such as meditation or progressive relaxation, to relieve the tension that sometimes prevents initiation of sleep. Reviewing factors that influence sleep can assist the patient to diagnose and remove barriers to sleep. Cognitive therapy could be helpful in combating the hopelessness verbalized by the patient. Alcohol consumption actually disrupts sleep. Becoming overtired may be a barrier to nighttime sleep. Naps may help replace lost sleep, but lengthy daytime sleep will prevent the patient from sleeping well at night.

1. The next-to-last meeting of an interpersonal therapy group is taking place. The leader should take which actions? (Select all that apply.) a. Support appropriate expressions of disagreement by the group's members. b. Facilitate discussion and resolution of feelings about the end of the group. c. Encourage members to reflect on their progress and that of the group itself. d. Remind members of the group's norms and rules, emphasizing confidentiality. e. Help members identify goals they would like to accomplish after the group ends. f. Promote the identification and development of new options for solving problems.

ANS: B, C, E The goals for the termination phase of groups are to prepare the group for separation, resolve related feelings, and prepare each member for the future. Contributions and accomplishments of members are elicited, post-group goals are identified, and feelings about the group's ending are discussed. Group norms are the focus of the orientation phase, and conflict and problem solving are emphasized in the working phase.

10. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

9. Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

15. Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

1. A married couple has two biologic children who live with them as well as a child from the wife's first marriage. What type of family is evident? a. Homogeneous b. Extended c. Blended d. Nuclear

ANS: C A blended family is made up of members from two or more unrelated families. It is not a nuclear family because a stepchild is present. It is not an extended family, because there are only two generations present. Homogeneous is not a family type.

2. A married couple has two children living in the home. Recently, the wife's mother moved in. This family should be assessed as a. nuclear. b. blended. c. extended. d. alternative.

ANS: C An extended family has members from three or more generations living together. Nuclear family refers to a couple and their children. A blended family is one made up of members from two or more unrelated families. An alternative family can consist of a same-sex couple or an unmarried couple and children.

15. A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

ANS: C Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.

10. A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

ANS: C Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.

5. A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

20. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

3. A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? a. Serum blood levels must be regularly monitored to assess for toxicity. b. To prevent side effects, the medication should be administered as an intramuscular injection. c. Eating foods such as blue cheese or red wine will cause side effects. d. This medication class may only be used safely for a few days at a time.

ANS: C MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.

23. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

18. A group is in the working phase. One member states, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a waste of my time." Which initial action by the group leader would be most therapeutic? a. Advise the member that hostility is inappropriate. Remove the member if it continues. b. Keep the group's focus on this member so the person can express the anger. c. Meet privately with the member outside of group to discuss the anger. d. Change to a more positive topic of discussion in this group session.

ANS: C Meeting privately with the member can convey interest and help defuse the anger so that it is less disruptive to the group. Removing the member would be a last resort and used only when the behavior is intolerably disruptive to the group process and all other interventions have failed. Decreasing the focus on the hostile member and focusing more on positive members can help soften the anger. Angry members often hide considerable vulnerability by using anger to keep others at a distance and intimidated. Changing the subject fails to respond to the behavior.

21. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient's treatment is complete.

ANS: C Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse's feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

21. A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: C Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.

6. A patient in a group therapy session listens to others and then remarks, "I used to think I was the only one who felt afraid. I guess I'm not as alone as I thought." This comment is an example of a. altruism. b. ventilation. c. universality. d. group cohesiveness.

ANS: C Realizing that one is not alone and that others share the same problems and feelings is called universality. Ventilation refers to expressing emotions. Altruism refers to benefitting by being of help to others. Group cohesiveness refers to the degree of bonding among members of the group.

15. Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system.

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.

17. A group is in the working phase. One member says, "That is the stupidest thing I've ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time." Which comment by the group leader would be most therapeutic? a. "You seem to think you know a lot already. Since you know so much, perhaps you can tell everyone why you are back in the hospital?" b. "I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about our group?" c. "It must be hard to be so angry." Direct this comment to another group member, "You were also angry at first but not now. What has helped you?" d. "I would like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others."

ANS: C The member's comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. "You seem to know a lot ..." conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.

7. A nurse at the well child clinic realizes that many parents have misconceptions about effective ways of disciplining their children. The nurse decides to form a group to address this problem. What should be the focus of the group? a. Support b. Socialization c. Health education d. Symptom management

ANS: C The nurse has diagnosed a knowledge deficit. The focus of the group should be education. Support and socialization are beneficial but should not be the primary focus of the group, and symptoms are not identified for intervention here.

13. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the patient. d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

4. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Tertiary c. Situational d. Organic

ANS: C A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. "Organic" and "Tertiary" are not types of crisis.

6. Acupuncture is a traditional Chinese medical treatment based on the belief that a. insertion of needles in key locations will drain toxic energies. b. pressure on meridian points will correct problems in energy flow. c. insertion of needles modulates the flow of energy along body meridians. d. taking small doses of noxious substances will alleviate specific symptoms.

ANS: C Acupuncture involves the insertion of needles to modulate the flow of body energy (qi) along specific body pathways called meridians. Acupressure uses pressure to affect energy flow. Homeopathy involves the use of microdosages of specific substances to effect health improvement. Traditional Chinese medicine (TCM) is more concerned with energy and life force balance, and acupuncture is not predicated on the removal of toxic energies.

3. A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

ANS: C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group b. A mental health center c. A women's shelter d. Vocational counseling

ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

2. Which clinical scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performs many rituals c. Paranoid delusions of being followed by alien monsters d. Completed alcohol withdrawal; beginning a rehabilitation program

ANS: C Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

14. A patient tells the nurse, "I prefer to treat my physical problems with herbs and vitamins. They are natural substances, and natural products are safe." Which response by the nurse would be most appropriate? a. "Natural substances tend to be safer than conventional medical remedies." b. "Natural remedies give you the idea that you are controlling your treatment." c. "The word natural can be a marketing term used to imply a product is healthy, but that's not always true." d. "You should not treat your own physical problems. You should see your health care provider for these problems."

ANS: C CAM remedies are usually natural substances, but it is a fallacy that products labeled natural are safer than conventional medicines. Some natural products contain powerful ingredients that can cause illness and damage to the body if taken inappropriately and, for some persons, can be dangerous even when used as directed. This is the most important message for the nurse to convey to the patient. So-called natural substances can have a number of significant side effects. Natural substances may give one the belief that he is controlling his own treatment, but that is not the message that most needs to be communicated here. Many patients can safely self-manage minor physical problems.

6. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

ANS: C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

19. A nurse conducting group therapy on the eating-disorder unit schedules the sessions immediately after meals for the primary purpose of a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.

ANS: C Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

2. A patient shows a nurse this advertisement: "Our product is a scientific breakthrough helpful for depression, anxiety, and sleeplessness. Made from an ancient formula, it stimulates circulation and excretes toxins. Satisfaction guaranteed or your money back." Select the nurse's best response. a. "Over-the-counter products for sleep problems are ineffective." b. "Do not take anything unless it's prescribed by your doctor." c. "Let's do some additional investigation of that product." d. "It sounds like you are trying to self-medicate."

ANS: C Helping consumers actively evaluate the quality of information available to them is important. It is important for the nurse to work with the patient and include the patient's preferences regarding management of health. Advertisements indicating scientific breakthroughs or promising miracles for multiple ailments are usually for products that are useless and being fraudulently marketed. Some may even be harmful. Some over-the-counter products can be useful, and patients do not need a prescription for these products. The broader issue is safety and efficacy, rather than whether the patient is trying to self-medicate.

11. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? a. "No complaints related to sexual function; to return next week." b. "Patient reports achieving orgasm last week; seems very happy." c. "Reports satisfaction with sexual encounters; feels partner is supportive." d. "Reports achieving orgasm occasionally; relationship with partner is adequate."

ANS: C Human sexuality, sexual expression, and expectations related to sexuality vary tremendously from person to person and across cultures. Therefore, the best indication of satisfactory treatment is that the patient is satisfied with what has been achieved. In this instance, "Patient reports satisfaction with sexual encounters; feels partner is supportive" best indicates that the patient is satisfied, and both presenting issues are progressing in a positive manner. Achieving orgasm once or occasionally may or may not represent satisfactory progress to the patient. "No complaints" does not necessarily mean that satisfaction exists.

16. A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has a. complaints of abdominal pain. b. repeated middle ear infections. c. bruises on extremities. d. diarrhea.

ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "What is going on?" b. "Please be quiet and sit down in this chair immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

ANS: C Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient's ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient's feelings and concerns. This leads to the next step of planning an intervention.

7. Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing? a. Maturational b. Mitigation c. Situational d. Recurring

ANS: C Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster's impact on human health and community function.

19. A patient's medical record documents sexual masochism. This patient derives sexual pleasure a. from inanimate objects. b. by inflicting pain on a partner. c. when sexually humiliated by a partner. d. from touching a nonconsenting person.

ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.

24. A patient diagnosed with depression confidently tells the nurse, "I've been supplementing my paroxetine with St. John's wort. It has helped a great deal." What is the nurse's priority action? a. Assess changes in the patient's level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of selective serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.

ANS: C St. John's wort inhibits serotonin reuptake by elevating extracellular sodium; thus, it may interact with medication, particularly selective serotonin reuptake inhibitors, to produce serotonin syndrome. Discussing the patient's birth control method is a secondary priority.

21. Which patient would most likely benefit from taking St. John's wort? A patient with a. mood swings. b. hypomanic symptoms. c. mild depressive symptoms. d. panic disorder with agoraphobia.

ANS: C St. John's wort may be effective in treating mild to moderate depression. St John's wort has not been found to be effective in treatment of cyclothymic, bipolar, or anxiety disorders.

15. A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by a. gently touching the patient's arm. b. asking the patient, "What do you need?" c. saying to the patient, "This is a safe place." d. directing the patient to cease the behavior.

ANS: C Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient's attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient's attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.

25. At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me get my life back in balance." The nurse responds, "I think we should have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency.

ANS: C Termination is indicated; however, the nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient shows no need for continuing support. The scenario does not describe dependency needs.

18. Which agency provides coordination in the event of a terrorist attack? a. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

ANS: C The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

11. A patient who is visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is a. 1 to 2 weeks. b. 3 to 4 weeks. c. 4 to 6 weeks. d. 8 to 12 weeks.

ANS: C The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

17. As a patient admitted to the eating-disorder unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5'4" tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

12. An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building b. Acute battering c. Honeymoon d. Stabilization

ANS: C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.

16. A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Your husband gets angry if you do not have dinner ready on time?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient's feelings.

23. Which complementary and alternative therapy may be safely combined with traditional Western medicine in the treatment of anxiety disorder? a. Electroconvulsive therapy b. Mega doses of vitamins c. Meditative practices d. Herbal therapy

ANS: C Yoga, meditation, and prayer are considered to be beneficial adjuncts to treatment for anxiety disorder. Research supports this with findings of lower catecholamine levels following meditation. Patient self-reports suggest patient satisfaction, with increased ability to relax. Meditation and spiritual practices have no associated untoward side effects. Herbal therapy and megadoses of vitamins have potential associated side effects and interactions. Electroconvulsive therapy is not CAM.

4. Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

ANS: C, D, E PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.

2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patient's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

1. A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.) a. Risk for caregiver strain b. Impaired verbal communication c. Risk for injury d. Imbalanced nutrition, less than body requirements e. Ineffective coping f. Sleep deprivation

ANS: C, D, F Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns. Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.

24. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

ANS: D In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

22. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

24. Which example of behavior in a family system demonstrates double bind communication? a. A mother tells her daughter, "You make me so mad that sometimes I wish I had never had you." b. A teenager tells her father, "You are treating me like a baby when you tell me I must be home by 10 PM on a school night." c. A son tells his mother, "You worry too much about what might happen. Nothing has happened yet, so why worry?" d. A wife tells her husband, "You go ahead with your bowling trip. Try not to worry about me falling on my crutches while I'm alone at home."

ANS: D A double bind communication is one that is inherently contradictory, that is, a comment that gives conflicting directions. In this case, the wife on crutches suggests that her husband should go bowling but then indicates that she will be at greater risk if he does, which in effect tells him "go ahead" and "don't do it" at the same time. This remark places the husband in a double bind, a situation in which no acceptable response exists. The distracters are clear, direct communications.

5. During a group therapy session, a newly admitted patient suddenly says to the nurse, "How old are you? You seem too young to be leading a group." Select the nurse's most appropriate response. a. "I am wondering what leads you to ask. Please tell me more." b. "I am old enough to be a nurse, which qualifies me to lead this group." c. "My age is not pertinent to why we are here and should not concern you." d. "You are wondering whether I have enough experience to lead this group?"

ANS: D A question such as this is common in the initial phase of group development when members are getting to know one another, dealing with trust issues, and testing the leader. Making explicit the implied serves to role model more effective communication and prompts further discussion of the patient's concern. Asking the patient to tell the leader more about the question focuses on the reason for the member's concern rather than on the issue raised (the experience and ability of the leader) and is a less helpful response. "I am old enough to be a nurse" and "age is not pertinent" are defensive responses and fail to address the patient's valid concern.

8. Which outcome would be most appropriate for a symptom-management group for persons diagnosed with schizophrenia? Group members will a. state the names of their medications. b. resolve conflicts within their families. c. rate anxiety at least two points lower. d. describe ways to cope with their illness.

ANS: D An appropriate psychoeducational focus for patients with schizophrenia is managing their symptoms; coping with symptoms such as impaired memory or impaired reality testing can improve functioning and enhance their quality of life. Names of medications might be appropriate for a medication education group but would be a low priority for symptom management. Addressing intra-family issues would be more appropriate within a family therapy group or possibly a support group. Rating anxiety lower would be an expected outcome for a stress-management group.

16. A nurse assesses a patient for inclusion in group therapy. This patient has a childhood history of neglect and ridicule by parents. The patient says to the nurse, "My boss always expects more of me than the others, but talking to him would only make it worse." Which type of group would best address the patient's needs? a. Support b. Self-Help c. Psychoeducational d. Cognitive-behavioral

ANS: D Cognitive-behavioral group therapy focuses on specific maladaptive behaviors and thought patterns. Patients often repeat patterns of behavior in a group that they learned in their families. This type of group will afford the patient an opportunity for a corrective recapitulation of the primary family group. The incorrect answers identify groups appropriate for other types of problems.

5. A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? a. 0 to 0.5 mEq/L b. 0.6 to 0.9 mEq/L c. 1.0 to 1.4 mEq/L d. 1.5 or higher mEq/L

ANS: D Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8 to 1.4 mEq/L are not likely to cause signs of toxicity.

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

20. A parent became unemployed 6 months ago. The parent has subsequently been verbally abusive toward the spouse and oldest child. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? a. Impaired parenting related to verbal abuse of oldest child b. Impaired social interaction related to disruption of family bonds c. Ineffective community coping related to fears about economic stability d. Disabled family coping related to insecurity secondary to loss of family income

ANS: D Disabled family coping refers to the behavior of a significant family member that disables his or her own capacity as well as another's capacity to perform tasks essential to adaptation. The distracters are inaccurate because the stressors influence more than one individual.

4. A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? a. The medication dose needs to be decreased. b. Treatment is successful, and medication can be stopped. c. The patient is ready to return to work. d. Specific assessment for suicide plan must be evaluated.

ANS: D Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.

1. A patient tells members of a therapy group, "I hear voices saying my doctor is poisoning me." Another patient replies, "I once heard voices too. They sounded real, but I found out later they were not. The voices you hear are not real either." Which therapeutic factor is exemplified in this interchange? a. Catharsis b. Universality c. Imitative behavior d. Interpersonal learning

ANS: D Here a member gains insight into his own experiences from hearing about the experiences of others through interpersonal learning. Catharsis refers to a therapeutic discharge of emotions. Universality refers to members realizing their feelings are common to most people and not abnormal. Imitative behavior involves copying or borrowing the adaptive behavior of others.

25. Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

12. Which remark by a group participant would the nurse expect during the working stage of group therapy? a. "My problems are very personal and private. How do I know people in this group will not tell others what you hear?" b. "I have enjoyed this group. It's hard to believe that a few weeks ago I couldn't even bring myself to talk here." c. "One thing everyone seems to have in common is that sometimes it's hard to be honest with those you love most." d. "I don't think I agree with your action. It might help you, but it seems like it would upset your family."

ANS: D In the working stage, members actively interact to help each other accomplish goals, and because trust has developed, conflict and disagreement can be expressed. Focusing on trust and confidentiality typically occur in the orientation phase as part of establishing group norms. Commonality and universality are also themes typically expressed in the orientation phase, whereas reflecting on progress is a task addressed in the termination phase.

6. A patient newly diagnosed with depression states, "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response? a. "There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not likely." b. "Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders." c. "All of your family members raised in the same area have probably learned to respond to problems in the same way." d. "Members of the same family may have the same biological predisposition to experiencing mood disorders."

ANS: D Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.

2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school.

ANS: D Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents a. visit their child's grave daily. b. maintain their child's room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

ANS: D Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.

10. Guidelines followed by the leader of a therapeutic group include focusing on recognizing dysfunctional behavior and thinking patterns, followed by identifying and practicing more adaptive alternate behaviors and thinking. Which theory is evident by this approach? a. Behavioral b. Interpersonal c. Psychodynamic d. Cognitive-behavioral

ANS: D The characteristics described are those of cognitive-behavioral therapy, in which patients learn to reframe dysfunctional thoughts and extinguish maladaptive behaviors. Behavioral therapy focuses solely on changing behavior rather than thoughts, feelings, and behaviors together. Interpersonal theory focuses on interactions and relationships. Psychodynamic groups focus on developing insight to resolve unconscious conflicts.

18. A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

ANS: D The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

7. The parent of an adolescent diagnosed with mental illness asks the nurse, "Why do you want to do a family assessment? My teenager is the patient, not the rest of us." Select the nurse's best response. a. "Family dysfunction might have caused the mental illness." b. "Family members provide more accurate information than the patient." c. "Family assessment is part of the protocol for care of all patients with mental illness." d. "Every family member's perception of events is different and adds to the total picture."

ANS: D The identified patient usually bears most of the family system's anxiety and may have come to the attention of parents, teachers, or law enforcement because of poor coping skills. The correct response helps the family understand that the opinions of each will be valued. It allows the nurse to assess individual coping and prepares the family for the experience of working together to set goals and solve problems. The other responses are either incorrect or evasive.

7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

ANS: D The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. Crying at 2 weeks after his death is expected and normal.

3. A young female member in a therapy group says to an older female member, "You are just like my mother, always trying to control me with your observations and suggestions." Which therapeutic factor of a group is evident by this behavior? a. Instillation of hope b. Existential resolution c. Development of socializing techniques d. Corrective recapitulation of the primary family group

ANS: D The younger patient is demonstrating an emotional attachment to the older patient that mirrors patterns within her own family of origin, a phenomenon called corrective recapitulation of the primary family group. Feedback from the group then helps the member gain insight about this behavior and leads to more effective ways of relating to her family members. Instillation of hope involves conveying optimism and sharing progress. Existential resolution refers to the realization that certain existential experiences such as death are part of life, aiding the adjustment to such realities. Development of socializing techniques involves gaining social skills through the group's feedback and practice within the group.

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

2. A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: D Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.

1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

ANS: D Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

4. Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should a. develop an understanding of human sexual response. b. assess the patient's sexual functioning and needs. c. acquire knowledge of the patient's sexual roles. d. clarify own personal values about sexuality.

ANS: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care.

2. Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

4. A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled nursing facilities increases an individual's tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAP's behavior as potentially harmful.

ANS: D Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

3. A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence

ANS: D Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

8. A woman said, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identify measures useful to help improve the couple's communication. b. The patient's feelings about the possibility of having a mastectomy c. Whether the husband is still engaged in an extramarital affair d. Clarify what the patient means by "I can't take anymore."

ANS: D During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

14. Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.

ANS: D Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

12. A student falsely accused a college professor of sexual intimidation. The professor tells the nurse, "I cannot teach nor do any research. My mind is totally preoccupied with these false accusations." What is the priority nursing diagnosis? a. Ineffective denial related to threats to professional identity b. Deficient knowledge related to sexual harassment protocols c. Impaired social interaction related to loss of teaching abilities d. Ineffective coping related to distress from false accusations

ANS: D Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations. This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor's crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

15. An immigrant from China needs a colonic resection but is anxious and reluctant about surgery. This patient usually follows traditional Chinese health practices. Which comment by the nurse would most likely reduce the patient's anxiety and reluctance? a. "Surgery will help rebalance the yin and yang forces and return you to harmony." b. "The surgery we are recommending will help you achieve final transformation." c. "I know this is new to you, but you can trust us to take very good care of you." d. "If you would like, we could investigate using acupuncture to help control pain."

ANS: D It would be helpful to incorporate elements of TCM as appropriate; such as acupuncture for pain control. TCM has the goal of healing in harmony with one's environment and all of creation in mind, body, and spirit, as well as balance of yin and yang energies and a state of transition. However, it would not be helpful to suggest that surgery will balance the yin and the yang, since this is not how balance is achieved in TCM. Transformation is recognized as a stage of healing occurring when mutual, creative, active participation occurs between healers and the patient toward changes in the mind, body, and spirit; but "final transformation" could imply the end of corporeal life and might be perceived as hastening his demise. Appealing to him to trust persons whose practices are foreign to him conflicts with the patient's values and would not likely be effective.

16. Which statement about paraphilic disorders is accurate? a. Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. b. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts. c. Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. d. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon.

ANS: D Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behaviors associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males in early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to the stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.

15. A patient with rheumatoid arthritis reports, "For the past month I've had trouble falling asleep. When I finally get to sleep, I wake up several times during the night." Which information should the nurse seek initially? a. "What have you done to try to improve your sleep?" b. "What would be a good sleep pattern for you?" c. "How much exercise are you getting?" d. "Do you have pain at night?"

ANS: D Patients with diseases such as arthritis may have sleep disturbance related to nightly pain. Because the pain is chronic, the patient may fail to realize it is the reason for the inability to sleep. The other options do not follow the patient's lead or begin problem solving without an adequate baseline.

23. A young adult says to the nurse, "I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs." Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)? a. "What type of birth control do you use?" b. "How much caffeine do you use every day?" c. "How much exercise do you get in a typical day?" d. "Does anyone else in your family have this problem?"

ANS: D RLS is a sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs accompanied by an urge to move. Symptoms begin or worsen during periods of inactivity, such as sleep. Symptoms can have a significant impact on the individual's ability to fall asleep and stay asleep. There is likely to be a strong genetic component, especially when seen in individuals less than 40 years old.

9. The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular

ANS: D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient's physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

4. A patient with a history of asthma says, "I've been very nervous lately. I think aromatherapy will help. I am ordering $250 worth of oils from an Internet site that promised swift results." Select the nurse's best action. a. Support the patient's efforts to become informed and to find health solutions. b. Suggest the patient check with friends who have tried aromatherapy for treatment of anxiety. c. Remind the patient, "If you spend that much on oils, you may not be able to buy your prescribed medication." d. Tell the patient, "Aromatherapy can complicateNURSINGTB.COM respiratory problems such as asthma. Let's consider some other options."

ANS: D Safety is paramount, and aromatherapy may cause complications for a patient with asthma. The nurse should view alternative treatments with an open mind and try to recognize the importance of the treatment to the patient while trying to give the patient accurate, reliable information about the treatment. Although efforts to become health literate should be supported, educating the patient about the pitfalls of relying on the Internet is essential. The opinions of others, whether they are positive or negative, lack a scientific basis and are subject to confounding variables such as the placebo effect and individual factors such as age and health history. Admonishing the patient may jeopardize the relationship.

21. A patient tells the nurse, "Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?" Select the nurse's best response. a. "Tell me about strategies you have tried to increase your total sleep hours." b. "Lack of sleep acts as a stressor on the body and can cause physical changes." c. "If you have really tried to sleep more, maybe you should consult your health care provider." d. "If you function well with 6 hours of sleep, you are a short sleeper. That's normal for some people."

ANS: D Some individuals require less sleep than others do. Those who need less are called "short sleepers," compared with "long sleepers," who require more than 8 hours. The distracters do not provide information the patient is seeking or are untrue.

22. Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hour b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range.

3. A patient wants to learn more about integrative therapies. Which resource should the nurse suggest for the most reliable information? a. Internet b. American Nurses Association (ANA) c. Food and Drug Administration (FDA) d. National Center for Complementary and Integrative Health (NCCIH)

ANS: D The NCCIH provides reliable, objective, and scientific information to help in making decisions about use of these practices. NCCIH supports not only research, but also the development and sharing of this kind of information. The FDA has information, but it is not as extensive as NCCIH. The Internet has many resources but some are unreliable. The ANA does not provide extensive information about this topic.

10. A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

ANS: D The correct response is the only strategy that questions the patient's distorted thinking.

10. A woman says, "I can't take anymore. Last year my husband had an affair and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention? a. The possible mastectomy b. The disordered family communication c. The effects of the husband's extramarital affair d. Coping with the reaction to the daughter's events

ANS: D The focus of crisis intervention is on the most recent problem: "the straw that broke the camel's back." The patient had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

19. A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which action by the nurse will best help to diffuse the patient's anger? a. Stop the dressing change and say, "I will leave the supplies so that you can change your own dressing." b. Continue the dressing change and say, "This dressing change is necessary because you were careless with fire." c. Discontinue the dressing change, tell the patient, "I will return when you gain control of yourself," and leave the room. d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

ANS: D The nurse should not respond personally to the patient's comments. The correct answer objectively gives the patient information that may lead to lowering his anger and engages the patient in problem solving. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness. Dressing changes are needed for the patient's physiological integrity; therefore, the nurse should not abandon the responsibility to perform them.

22. Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.

ANS: D The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

13. A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

5. A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D The patient's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

13. An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

ANS: D The patient's threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

18. A patient being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5'4". The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.

16. A 76-year-old man tells the nurse at the sleep disorder clinic, "I awaken almost nightly in the midst of violent dreams in which I am defending myself against multiple attackers. Then I realize I have been hitting and kicking my wife. She has bruises." Which health problem is most likely? a. Sleep paralysis b. Night terror disorder c. Sleep-related bruxism d. REM Sleep Behavior Disorder

ANS: D The scenario describes REM sleep behavior disorder in which the patient engages in violent and complex behaviors during REM sleep as though acting out his dreams. Older men have a higher incidence of this problem. Sleep paralysis refers to the sudden inability to perform voluntary movement at either sleep onset or awakening from sleep. Bruxism refers to grinding teeth during stage 2 sleep. Night terror disorder occurs as arousal in the first third of the night during NREM sleep, accompanied by feelings of panic.

20. A man with hypospadias tells the nurse, "Intercourse with my new bride is painful." Which term applies to the patient's complaint? a. Delayed ejaculation b. Erectile dysfunction c. Premature ejaculation d. Genito-pelvic pain/penetration disorder

ANS: D This sexual pain is genito-pelvic pain/penetration disorder and may occur in men or women. The individual feels pain in the genitals during intercourse. Erectile or ejaculation problems are not evident. See relationship to audience response question.

5. A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, "Without the red teddies, I am not interested in sex." The nurse can assess this as consistent with a. exhibitionism. b. voyeurism. c. frotteurism. d. fetishism.

ANS: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously. Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations.

A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. assume roles and functions of other family members. b. demonstrate performance of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet personal needs.

B The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.

A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. marginally successful. b. minimally successful. c. partially successful. d. totally achieved.

C Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

A patient diagnosed with a somatic symptom disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.

C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient's diagnosis has been established.

Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively? a. Flooding c. Relaxation techniques b. Response prevention d. Systematic desensitization

C Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the patient's perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders.

A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a."I'm not comfortable doing that," and then ignore subsequent requests for early medication. b."I understand that you have pain, but giving medicine too soon would not be safe." c."I'll have to check with your doctor about that; I will get back to you after I do." d."It would be unsafe to give the medicine early; none of us will do that."

I understand that you have pain, but giving medicine too soon would not be safe

When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include a.preoccupation with minute details; perfectionist. b.charm, drama, seductiveness; seeking admiration. c.difficulty being alone; indecisive, submissiveness. d.grandiosity, self-importance, and a sense of entitlement.

grandiosity, self importance, and a sense of entitlement

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is a.nonadherence. b.impaired social interaction. c.disturbed personal identity. d.diversional activity deficit.

impaired social interaction

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money." These statements show a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

lack of guilt feelings

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as a.seductive. b.detached. c.manipulative. d.guilt-producing.

manipulative

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include a.arrogant, grandiose, and a sense of self-importance. b.attention seeking, melodramatic, and flirtatious. c.impulsive, restless, socially aggressive behavior. d.socially anxious, rambling stories, peculiar ideas.

socially anxious, rambling stories, peculiar ideas