Psych Adaptive Quiz
A school nurse is teaching a group of teachers' aides about the play characteristics of 5-year-old kindergartners. In what type of play do these children engage?
cooperative
What should the nurse keep in mind about rituals when planning care for a client who uses ritualistic behavior?
they help the client control anxiety.
What suggestions should the nurse give to a family to foster developmental changes in an adolescent child? Select all that apply.
"Start focusing on midlife material and career issues." "Shift your attention to the concerns of older people." "Work on letting your adolescent move in and out of the family."
An adolescent experiencing a vaso-occlusive crisis reports right knee pain. What is the most appropriate nursing intervention?
Applying a warm soak to the knee
A nurse is caring for a 7-year-old child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention?
Checking radial pulses
An unmarried female adolescent arrives at a hospital with her parents. She complains of a delay in her regular menstrual cycle and wants to confirm her health status. Which strategies should be employed while interviewing the adolescent? Select all that apply.
Gaining the client's trust Explaining the limits of confidentiality
A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Placing the child in the side-lying position
What are the greatest risks for injury for an adolescent? Select all that apply.
Substance abuse Automobile Accidents
While questioning a rape victim, the nurse discovers that the victim does not remember anything related to the assault. Of the following, which is the most probable cause of the victim's memory loss?
The rape victim was drugged with flunitrazepam.
The nurse is reviewing discharge instructions for a mother whose lactose intolerant school-aged child was recently found to have celiac disease. Which statements by the mother demonstrate understanding of the child's nutritional needs? Select all that apply.
"I'll try to provide meals that are lower in fats and higher in carbohydrates." She loves raw carrots for snacking, so I'll have to avoid those when the disease is worse." "I'll be sure to look at the labels more closely from now on—we need to avoid hydrolyzed vegetable protein."
A client with the diagnosis of borderline personality disorder is manipulative and uses this behavior to get cigarettes from other clients. One day the client begins to badger another client. What should the nurse say while removing the client from the area?
"You must leave people alone; this behavior is unacceptable. Limits must be set when the client's behavior physically or emotionally imposes on other clients. This is achieved with the response "You must leave people alone; this behavior is unacceptable." The response "There will be consequences if you do not stop annoying people" is a threat and is contraindicated. Although the response "Tell me how you feel when you are exerting control over people" is an exploration of feelings, which is important, the priority at this time is to set limits and protect the other clients. The response "I'm surprised you're still bothering people; you seemed to have improved lately" devalues the client and may precipitate feelings of guilt.
A client with bipolar I disorder, manic episode, is admitted to the mental health unit of a community hospital. When developing an initial plan of care for this client, what should the nurse plan to do?
3 Encourage increased nutritional intake. The client in a manic episode of the illness often neglects basic needs; these needs are a priority to ensure adequate nutrition, fluid, and rest. The hyperactivity of mania creates an increased need for calories. Although the client needs to expend excess energy, physical exhaustion and dehydration are real possibilities during the manic episode of the illness. Isolating the client from peers is counterproductive and punitive. The client is unable to actively participate in group activities at this time.
A confused, hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?
4 "It can be frightening to feel that way." Depersonalization communication is the result of a high anxiety level; projecting empathy to the client will facilitate exploration of concerns. The response "May I examine your arms?" does not acknowledge the frightening experience for the client and supports the client's hallucination. When the feeling started is irrelevant; the nurse must address what the client is experiencing now. The response "That's a rather unusual sensation" belittles the client's feelings and may make establishment of a therapeutic relationship difficult.
A nurse working the 7 am to 3 pm shift is caring for a 14-year-old adolescent for whom intake and output are being monitored. The primary healthcare provider prescribes an intravenous infusion to be administered at a rate of 50 mL/hr. The adolescent had 4 oz (120 mL) of milk and a muffin for breakfast at 8:30 am. At 9 am the adolescent vomited 200 mL. At 10 am the adolescent had 60 mL of water with medications. At 11 am the adolescent voided 550 mL of urine. For lunch, at 12:30 pm, the adolescent ate 3 oz (90 mL) of soup and 4 oz (120 mL) of ice cream. The adolescent voided 450 mL at 2 pm. Calculate the adolescent's total intake for the 7 am to 3 pm shift. Record your answer using a whole number. _____ mL
790
A client with a diagnosis of major depression refuses to participate in unit activities, claiming to be "just too tired." What is the best nursing approach?
Accepting the client's feelings about activities calmly while setting firm limits Fatigue and apathy are symptoms of depression and should be accepted; however, limits should be set to facilitate participation in unit activities. Planning one rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them.
A 6-year-old child with Reye syndrome is admitted to the pediatric intensive care unit. What clinical finding does the nurse deem the most significant when assessing this child?
Altered consciousness
What are the pathophysiologic factors of acne? Select all that apply.
Correct1 Comedogenesis Correct2 Production of excessive sebum Correct3 Alteration in follicular growth Correct5 Colonization of Propionibacterium acnes
A nurse provides nutrition instruction to the parents of a school-aged child with celiac disease, including foods that their child may safely eat. What foods selected by the parents indicate that the teaching has been successful?
Hamburger patty and fries
In an outpatient mental health clinic a nurse is working with a client who is beginning to address more effective ways to handle stressful situations. The best nursing action to include in the plan of care is to have the client do what?
Identify unhealthy habits that need to be altered. The identification of unhealthy habits or specific problems will allow the client to determine which additional coping skills need to be developed and practiced. A rehabilitation program is more appropriate for clients with psychotic or substance abuse disorders, not clients who are experiencing anxiety. Further assessment is required before initiation of the use of medication. Although a consistent method for performing self-care is important, it is not the priority.
A 10-year-old child has been working on earning all of the scouting badges. Which of Erikson's stages of psychosocial development is this child achieving?
Industry
Which priority actions should the nurse implement when providing care to a toddler-age child who presents in the emergency department (ED) after an accidental overdose? Select all that apply.
Monitor vital signs Assess mental status Initiate CPR, if needed
A nurse in the clinic is assessing a teenager with a tentative diagnosis of primary syphilis. What is an early sign of this infection?
genital lesion
A 5-year-old child is admitted to the pediatric intensive care unit with a diagnosis of acute asthma. A blood sample is obtained to measure the child's arterial blood gases. What finding does the nurse expect?
Increased carbon dioxide level
A toddler is being discharged after myringotomy. What potential complications should the nurse teach the child's parents to report? Select all that apply.
Increased pain Lack of drainage
After a conference with the primary healthcare provider, a client with a borderline personality disorder cries bitterly, pounds the bed in frustration, and threatens suicide. What is the most helpful response by the nurse?
Staying with the client and listening attentively if the client wishes to talk about the problem Sitting with the client indicates acceptance and demonstrates that the nurse feels that the client is worthy of the nurse's time. It is better to stay with the client quietly until control is regained; staying prevents a follow-through on the client's threat. Patting the client reassuringly on the back and saying, "I know that it's hard to bear" provides little comfort for the client. Asking about the client's troubles and answering, "Other people also have problems" may close off further communication.
An older adult client who is confused and often does not recognize family members is admitted to a nursing home. The client appears slovenly, often soiling clothing with feces and urine. How can the nurse best manage this problem?
Toileting the client every 2 hours This client needs toileting every 2 hours to prevent soiling; physically seating the client on the toilet often prevents accidents and negates the need for disposable pads or underwear. The client has cognitive impairment, and reality orientation will probably be ineffective. The client needs more than just supervision. The client may be unable to control the incontinence, and saying that the behavior is offensive is demeaning.Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.
According to Tanner stages, which figure indicates the pubertal stage in males?
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A nurse is assessing a client with bulimia nervosa. What should the nurse ask to obtain information about the client's intake habits and patterns?
"How frequently are you eating in response to your feelings rather than because you're hungry?" Clients with bulimia nervosa [1] [2] have a history of eating as a response to strong internal feelings rather than as a response to the sensation of hunger. Clients with anorexia, not bulimia, often feel powerless and tend to use restrictive eating as a way to enhance a personal sense of control, not to control others. Clients with bulimia nervosa usually eat excessive amounts of food when alone rather than with others. They know that their behavior is dysfunctional and attempt to hide it from others. Binge eating usually is not associated with a woman's menstrual cycle.
The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?
"I didn't hear anyone talking; come with me to your room." The nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.
A 12-year-old girl is admitted to the pediatric unit with a diagnosis of meningococcal meningitis. Three days after admission the child is afebrile and asymptomatic but appears sad and cries frequently. How should the nurse help the child verbalize her thoughts and feelings?
By telling the child that she seems sad and upset
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the most appropriate action by the nurse?
Continuing to observe the seizure The child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. Oxygen is useless until the child breathes when the seizure is over. The practitioner may be notified later; provisions for the child's safety and observation are the priorities.
Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. What is the most important intervention for the client who is given an as-needed (PRN) medication and confined to involuntary seclusion?
Correct2 Evaluate the client's progress toward self-control For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.Test-Taking Tip: Choose the best answer for questions asking for a single answer. More than one answer may be correct, but one answer may contain more information or more important information than another answer.
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." What does the nurse conclude that the client is exhibiting?
Correct3 Delusional thinking Delusions are false fixed beliefs that have a minimal basis in reality. This is a somatic delusion. Ideas of reference are false beliefs that every statement or action of others relates to the individual. Loose associations are verbalizations that sound disjointed to the listener. Tactile hallucinations are false sensory perceptions of touch without external stimuli.
Which criteria in a client must be assessed in order to diagnose premenstrual dysphoric disorder (PMDD)? Select all that apply.
Symptoms such as irritability, anxiety, or depressed mood Correct5 Symptoms that interfere with work or interpersonal relationships
