Psych - Exam 3 Review Questions
A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself you know!" Which of the following responses should the nurse give the client? A. "We do this every day. Why are you so angry with me this morning?" B. "I don't like it when you address me with that tone of voice." C. "I know you can, but are you going to read it or not?" D. "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
"I don't like it when you address me with that tone of voice."
A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion? "I like to cut my food into small pieces." "I really need to get into shape." "If I eat one piece of candy, I may as well eat ten." "I can't afford to gain weight."
"If I eat one piece of candy, I may as well eat ten."
The nurse interviews the parent of a 7-year-old child diagnosed with moderate autism spectrum disorder. Which comment from the parent best describes autistic behavior? a. "My child occasionally has temper tantrums." b. "Sometimes my child wakes up with nightmares." c. "My child swings for hours on our backyard gym set." d. "Toilet training was more difficult for this child than my other children."
"My child swings for hours on our backyard gym set."
A nurse is teaching the parents of a child who has ADHD about methylphenidate. Which of the following statements should the nurse include in the teaching? A. "Administer the medication at bedtime." B. "Your child might gain weight while taking this medication." C. "This medication might increase the amount of saliva your child produces." D. "Restrict your child's intake of caffeine while she is taking this medication."
"Restrict your child's intake of caffeine while she is taking this medication."
The husband of a client diagnosed with somatic symptom disorder asks the nurse, "What causes this condition?" Which response by the nurse would be most accurate? "There is definitely an underlying genetic link for this disorder." "Your wife is experiencing chronic stress that causes hypoarousal." "The symptoms reflect an emotion that your wife cannot verbalize." "The symptoms reflect an internal preoccupation with events."
"The symptoms reflect an emotion that your wife cannot verbalize."
After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder? "These sandwiches are probably contaminated with bacteria." "I suppose it's the best we can hope for under these circumstances." "You should have ordered a to-go meal from a local restaurant for me." "I would rather wait to eat until the dietary department can prepare a meal."
"You should have ordered a to-go meal from a local restaurant for me."
A nurse is caring for an elderly client who arrived at the emergency room with injuries following a physical assault with a baseball bat. The client tells you that their son is responsible for the injuries. Place the following nursing actions in order from the highest importance to the lowest importance. All options must be used. a. Remove the significant other from the room with the client. b. Conduct an assessment of the client. c. Notify the physician of the client's injuries and situation. d. Notify the police of the assault. a. 1a, 2b, 3c, 4db. 1b, 2a, 3c, 4dc. 1d, 2c, 3a, 4bd. 1c, 2a, 3b, 4d
1) Remove the significant other from the room with the client. 2) Conduct an assessment of the client. 3) Notify the physician of the client's injuries and situation. 4) Notify the police of the assault.
One bed is available on the inpatient eating disorders unit. Which patient experiencing a weight loss should be admitted? a. 150 to 100 pounds over a 4-month period. Vital signs: 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: 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: 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: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg.
150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg.
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A. A client wants to know the current time while there is a clock on the wall. B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client requests extra blankets when the thermostat in the room indicates 78.0F. D. A client refuses to get out of bed and has no motivation to attend to daily hygiene
A client attempts to climb out of bed and repeatedly states she must get home.
Which characteristic of individuals diagnosed with personality disorders makes it most necessary for staff to schedule frequent meetings? Ability to achieve true intimacy Flexibility and adaptability to stress Ability to evoke interpersonal conflict Inability to develop trusting relationships
Ability to evoke interpersonal conflict
A nursing instructor is preparing a presentation on the etiology of Alzheimer's disease (AD). When discussing the role of neurotransmitters in the course of the disease, which of the following would the instructor most likely emphasize? a. Serotonin b. Acetylcholine c. Dopamine d. Norepinephrine
Acetylcholine
A nurse is working with a client diagnosed with factitious disorder. Which of the following is most important for the client to do first when beginning treatment? Acknowledge the deception Understand the underlying issues Identify the behavior Develop an alternative response
Acknowledge the deception
Jane was brought into the emergency department following a complaint of rape. The patient has moments of agitation, tearfulness, Symptoms include shock, numbness, disbelief, disorganization in lifestyle, cognitive impairment with confusion, poor concentration, poor decision making, and somatic symptoms.What phase in rape-trauma syndrome is the patient experiencing? a. Acute Phase b. Long-term phase
Acute Phase
A nurse is caring for a client who has severe manifestations of acute alcohol withdrawal. To ensure safe care, which of the following nursing actions should the nurse take? (Select all that apply.) A. Administer a benzodiazepine. B. Keep the lights on in the client's room. C. Ambulate the client in the hallway. D. Reduce unnecessary stimuli. E. Limit daily fluid intake.
Administer a benzodiazepine. Keep the lights on in the client's room. Reduce unnecessary stimuli.
The inability to recognize common/familiar objects
Agnosia
A nurse should anticipate that which symptoms of Alzheimer's disease will become apparent as the disease progresses from stage 3, moderate to severe to stage 4, late stage? (Select all that apply.) a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory
Agraphia Hyperorality Hypermetamorphosis
A known alcoholic presents to ED with tachycardia, elevated BP, & diaphoresis. These are signs and symptoms of ___? A.Intoxication B.Alcohol Withdrawal C.Tolerance D.Both A & B
Alcohol Withdrawal
It has been 72 hours since Patient John has had any alcohol. Previously patient admits to drinking twelve 8 oz. Vodkas a day. The patient presented to the ED complaining of visual hallucinations. The patient is diaphoretic, agitated, and excitable. His vital signs are as follows:BP: 180/96HR: 135Temp:101.2This patient may be suffering from a. Hyponatremia b. Alcohol Withdrawal Delirium c. Alcohol Poisoning d. Neuroleptic Malignant Syndrome
Alcohol Withdrawal Delirium
Assessment of Personality Disorder Patients should include Suicidal/Aggressive Ideation Current use of medication Substance Abuse Legal History All of the above
All of the above
Documentation for a patient seen in the ED for rape should include? Select all that apply A.Threats B.Location of Incident C.Circumstances surrounding the assault D.Verbatim verbiage E.All of the above
All of the above
Terror of gaining weight and feelings of being overweight when patient is actually emaciated are characteristics of what eating disorder? Bulimia nervosa Anorexia nervosa Rumination Disorder Pica
Anorexia nervosa
A person shoplifts merchandise from a community cancer thrift shop. When confronted, the thief replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder? Antisocial Histrionic Borderline Schizotypal
Antisocial
This personality disorder shows callousness, entitlement, lack of remorse, and disregard for the rights of others.
Antisocial
The inability to express language
Aphasia
A nurse is assessing a client who is suspected of having conversion disorder (functional neurologic symptom disorder). Which finding would the nurse most likely expect to assess? Select all that apply. Enhanced touch sensation Aphonia Urinary frequency Impaired coordination Diarrhea Difficulty swallowing
Aphonia Impaired coordination Difficulty swallowing
The loss of purposeful movement
Apraxia
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should implement what intervention to assess patient safety? a. Assess lung sounds and extremities. b. Suggest the 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.
Assess lung sounds and extremities.
A patient has progressive memory deficit 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. Promote the use of the patient's sense of humor by telling jokes.
Assist the patient to perform simple tasks by giving step-by-step directions.
89 yo. Dementia patient becomes frightened when he hears a doorbell because he doesn't recognize the sound. This is known as A.Auditory agnosia B.Apraxia C.Aphasia D.Sun downing
Auditory agnosia
A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication? A. Invite a family member to be present for the nursing history. B. Provide basic wound care for obvious physical injuries. C. Probe the client to offer a factual account of the abuse. D. Be direct and honest when speaking with the client.
Be direct and honest when speaking with the client.
Therapy that examines and supports change in behaviors might affect life negatively or cause distress. Cognitive Behavioral Therapy Dialectical Behavior Therapy Psychodynamic therapy Behavioral Therapy
Behavioral Therapy
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)
Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
Name that PD: The Patient admits to difficulty maintaining relationships, poor impulse control, chronic feelings of emptiness & fear of abandonment. Borderline Personality Disorder Narcissistic Personality Disorder Antisocial Personality Disorder Paranoid Personality Disorder
Borderline Personality Disorder
_________________________ is characterized by unstable relationships, unstable affect, feelings of abandonment and chronic feelings of emptiness.
Borderline Personality Disorder
A 22 year-old patient presents to the ED with depression, binge eating, and self-induced vomiting. These are characteristics of what eating disorder? Bulimia nervosa Anorexia nervosa Rumination Disorder Pica
Bulimia Nervosa
characterized by binge eating and self-induced vomiting, the inappropriate use of laxatives, diuretics, depression, anxiety, possible chemical dependency and possible impulsive stealing. Bulimia nervosa Anorexia nervosa Rumination Disorder Pica
Bulimia Nervosa
Therapy that focuses on identifying and changing thought patterns and perceptions they might negatively affect the individual. Cognitive Behavioral Therapy Dialectical Behavior Therapy Psychodynamic therapy Behavioral Therapy
Cognitive Behavioral Therapy
A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for which disorder? a. Attention-deficit/hyperactivity disorder (ADHD) b. Childhood depression c. Conduct disorder (CD) d. Autism spectrum disorder (ASD)
Conduct disorder (CD)
A nurse assesses a 3-year-old diagnosed with autism spectrum disorder. Which finding is most associated with the child's disorder? a. Has occasional toileting accidents. b. Is unable to read children's books. c. Cries when separated from a parent. d. Continuously rocks in place for 30 minutes.
Continuously rocks in place for 30 minutes.
Mr. Smith, a 78 year-old male, was alert and oriented to person, place, time, and situation during the shift yesterday. Today Mr. Smith is AAO to self only. He is able to state his name correctly but thinks the date is 1985, he is at home, and is unaware of his current medical status. Mr. Smith may be experiencing? A.Delirium B.Dementia C.Hypoglycemia D.Huntingtons
Delirium
Sudden loss in orientation and disturbances in consciousness. The patient will typically be mindful of self but will become confused with regards to time, place, and situation.
Delirium
A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial
Denial
The provider explains to the patient diagnosed with Borderline PD that which is the most effective treatment? Cognitive Behavioral Therapy Dialectical Behavior Therapy Psychodynamic therapy Behavioral Therapy
Dialectical Behavior Therapy
A cognitive behavioral therapy that is considered the most effective treatment with borderline personality disorder. It targets the following: 1. Decreasing life-threatening suicidal behaviors 2. Decreasing therapy-Interfering behaviors 3. Decreasing quality of life interfering behaviors 4. Increasing behavioral Skills Cognitive Behavioral Therapy Dialectical Behavior Therapy Psychodynamic therapy Behavioral Therapy
Dialectical Behavior Therapy (DBT)
A disorder defined as the disturbance in the continuum of consciousness, memory identify and perception. Factious Disorder Factious Disorder by proxy Illness Anxiety Disorder Dissociative Disorder
Dissociative Disorder
76 yo. patient presents with aphasia, incontinence, is non-ambulatory, AAO x 0, with a Stage 4 sacral pressure ulcer. What stage of Alzheimer's has the patient reached? A.Stage 2 (moderate) B.Stage 1 (mild) C.Stage 3 (moderate-severe) D.End Stage
End stage
A nurse is planning to explain the purpose of the behavioral therapy technique of self-monitoring to a client with bulimia nervosa. The nurse would emphasize keeping a diary to record what? a. Feelings of hunger b. Environmental cues c. Efforts at distraction d. Rigid rules about eating
Environmental cues
A patient diagnosed with a personality disorder has used manipulation to get their needs met. The staff decides to apply limit setting interventions. What is the correct rationale for this action? It provides an outlet for feelings of anger and frustration. It respects the patient's wishes so assertiveness will develop. External controls are necessary while internal controls are developed. Anxiety is reduced when staff members assume responsibility for the patient's behavior.
External controls are necessary while internal controls are developed.
Formerly referred to as Munchausen syndrome, ___________________________ refers to a patient that self-inflicts injury or fabricates injury without obvious external reward or gain. Factious Disorder Factious Disorder by proxy Illness Anxiety Disorder Dissociative Disorder
Factious Disorder
Formerly referred to as Munchausen syndrome by proxy, _____________________is the fabrication of injury imposed on others. Factious Disorder Factious Disorder by proxy Illness Anxiety Disorder Dissociative Disorder
Factious Disorder by proxy
Intentionally faking symptoms in order to assume the sick role, that is, to be a patient.
Factitious Disorder
By virtue of the legal definition of the relationship, rape cannot occur within a marriage. True False
False
The only treatment for childhood ADHD is medication therapy with Ritalin. True or False
False
A group of nurses is reviewing information about delirium and dementia. The nurses identify which as a characteristic of delirium? a. Fluctuating changes within a 24-hour period b. Progressive memory loss c. Normal psychomotor activity d. Globally impaired cognition
Fluctuating changes within a 24-hour period
Chronic or brief symptoms of altered voluntary motor or sensory function that cause substantial distress or psychosocial impairment.
Functional neurological disorder (FND)
A daughter brings her mother, who has Alzheimer's disease, to the clinic. The client has been taking a cholinesterase inhibitor medication for 1 month. When assessing the client, the nurse would be alert for the possibility of which side effect? a. Gastrointestinal distress b. Mild headache c. Muscle tics d. Blurred vision
Gastrointestinal distress
The preoccupation of developing a serious illness can be defined as: Factious Disorder Factious Disorder by proxy Illness Anxiety Disorder Dissociative Disorder
Illness Anxiety Disorder
Preoccupied with having or eventually developing a serious illness.
Illness anxiety disorder
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is a safety risk? A. Vitamin deficiency B. Diaphoresis C. Tremors D. Illusions
Illusions
A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestations seen in the moderate stage of Alzheimer's disease? (Select all that apply.) A. Inability to find commonly used items B. Inability to perform common tasks C. Difficulty with talking or reading D. Difficulty remembering how to swallow E. Inability to recognize family members
Inability to perform common tasks Difficulty with talking or reading
A nurse plans care for a patient diagnosed with borderline personality disorder. Which nursing diagnosis is most likely to apply to this patient? Ineffective relationships related to frequent splitting Social isolation related to fear of embarrassment or rejection Ineffective impulse control related to violence as evidenced by cruelty to animals Disturbed thought processes related to recurrent suspiciousness of people and situations
Ineffective relationships related to frequent splitting
A nurse is working with a client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which would be most important for the nurse to do? a. Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence. b. Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client. c. Assist the client in finding a new apartment and a new job so to be safe after leaving the current situation. d. Suggest that the client legally change his or her name and move out of state to be safe from future harm.
Inform the client that if leaving the abusive situation, there is a possibility the partner will attempt to fatally injure the client.
A client is admitted to a mental health unit with a diagnosis of factitious disorder. When reviewing the client's history, which would a nurse most likely find? Intentional self-injurious behavior Pain to achieve a self-serving goal Malingering to avoid work Parents who were restrictive
Intentional self-injurious behavior
Psychosocial theorists propose that somatic symptom illnesses are an indirect expression of stress and anxiety through physical symptoms. Which is the primary defense mechanism used in somatoform disorders? Somatization Identification Internalization Repression
Internalization
A patient presents with mechanical fall resulting in multiple lacerations, extensive facial bruising & jaw fracture. The patient should be evaluated for____ A.Self-Mutilation B.Anxiety Disorder C.Intimate Partner Violence D.Borderline Personality Disorder
Intimate Partner Violence
The nurse is leading a family therapy group for clients and families of individuals who are addicted to substances. The family of a cocaine addict is angry and cannot understand why the client cannot just stop using. The nurse guides the group to discuss their understanding of the nature of addiction. Which statements would the nurse identify as an accurate understanding of the nature of addiction? Select all that apply. a. It is a medical illness that is progressive. b. The client will eventually be cured. c. Relapses and remissions are part of the illness. d. Clients can learn to get control over the substance.
It is a medical illness that is progressive. Relapses and remissions are part of the illness.
A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? a. Another beating by the abusive partner b. Love, gifts, and praise from the abusive partner c. A brief period during which the partners ignore each other d. The abusive partner leaves the relationship for a short time
Love, gifts, and praise from the abusive partner
A college student reports that, "My vision is too blurry to read effectively, especially when it's time to be studying for a test." Which health problem should be considered initially? Malingering Illness anxiety Factitious disorder Functional neurological disorder
Malingering
Intentionally faking or exaggerating symptoms for an obvious benefit such as money, housing, medications, avoiding work, or criminal prosecution.
Malingering
A client is experiencing severe alcohol withdrawal. Which would the nurse most likely assess? Select all that apply. a. Heart rate around 100 beats/min b. Marked diaphoresis c. Auditory hallucinations d. Gross uncontrollable tremors e. Increased appetite
Marked diaphoresis Auditory hallucinations Gross uncontrollable tremors
Nurse Teaching for a patient with an eating disorder might include? Select all that apply? If you gain the weight back, you are cured Meal planning that includes a healthy diet and exercise Coping Skills Acknowledgement of effects of binging, purging & cognitive distortions
Meal planning that includes a healthy diet and exercise Coping Skills Acknowledgement of effects of binging, purging & cognitive distortions
Johnny Smith is a 12 year-old boy brought in for assessment of aggressive behaviors. He frequently becomes vindictive and angry with his teachers, deliberately irritates his classmates and blames his bad behavior on others. Johnny displays characteristics of___________________? A.Conduct disorder B.Oppositional defiant disorder C.Paranoia D. Intermittent Explosive Disorder
Oppositional defiant disorder
A common occurrence during the Long-term phase of rape-trauma syndrome is______? A.PTSD B.Patients recover without any side effects C.Drug Abuse
PTSD
While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? (Select all that apply.) a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever
Prevention of seizures Reduction of fever
A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion? A. Active psychiatric disorder B. Previous suicide attempt C. Loss of a parent D. History of substance abuse
Previous suicide attempt
A client has just presented at the emergency department after being raped. What initial action by the nurse would be most appropriate? a. Provide emotional support b. Refer the client to a rape crisis hotline c. Encourage the client to file charges immediately d. Perform a nursing history and physical as quickly as possible.
Provide emotional support
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 focus on what? Encouraging the patient to express anger Providing care in a kind but matter-of-fact manner Demonstrating sympathy and concern Offering to listen to the patient's feelings about cutting
Providing care in a kind but matter-of-fact manner
Therapy that explores connections between the unconscious mind and actions (emotions, relationships,& thought patterns.) Cognitive Behavioral Therapy Dialectical Behavior Therapy Psychodynamic therapy Behavioral Therapy
Psychodynamic therapy
A pediatric patient reports to their RN that they have been abused at home. The RN should... A.Do nothing as children are unreliable B.Report the information to the parent and seek corroboration C.Report suspected abuse to appropriate child protective agency D.Assess parent/child interaction to assess for abusive behavior
Report suspected abuse to appropriate child protective agency
To assist a patient diagnosed with a somatic system disorder, which nursing intervention is of highest priority? Implying that somatic symptoms are not real Helping the patient suppress feelings of anger Shifting the focus from somatic symptoms to feelings Investigating each physical symptom as soon as it is reported
Shifting the focus from somatic symptoms to feelings
__________________is the inability to integrate both the positive and the negative qualities of an individual into one person.
Splitting
What stage of Alzheimer Disease? Forgetfulness: Short term memory loss, depression, disease is not yet diagnosable based on symptoms.
Stage 1 (mild)
What stage of Alzheimer Disease? Confusion: Progressive memory loss, social withdrawal, decrease in ADL, denial, Depression, needs day care or home assistance
Stage 2 (moderate)
What stage of Alzheimer Disease? Loss of ADL, Loss of reasoning, safety, and verbal communication, aphasia, institutional care needed
Stage 3 (moderate to severe)
A state of confusion occurring in the late afternoon and going into night. It may cause anxiety confusion, aggression and lead to wandering.
Sun downing
An unresponsive patient presents to the ED after mixing alcohol & a benzodiazepine. This is an example of a. Confabulation b. Synergistic Effect c. Blackout d. Intoxication
Synergistic Effect
Betty's husband has increasingly become more agitated with the way the Betty tends to the home and children. He has slapped her in the face on occasion and is verbally abusive daily. Which phase of the abuse cycle is Betty's husband in? a. The Honeymoon phase b. The Tension Building Phase c. Acute Battering Phase
The Tension Building Phase
A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the client's distress? A. The client demonstrated an allergic response to the medication. B. The client experienced a common side effect to the medication. C. The client consumed alcohol while taking the medication. D. The client took an overdose of the medication.
The client consumed alcohol while taking the medicatio
The nurse is working in the emergency department with a client who was raped 1 hour ago. Which is most important for the nurse to remember when planning care? a. The client should set aside any angry feelings until physical care is completed. b. Evidence collection according to procedures is not as important as treating the client's injuries. c. The nurse will need to make decisions for this client. d. The client may feel threatened by some of the procedures.
The client may feel threatened by some of the procedures.
Which are appropriate long-term treatment outcomes for clients who have somatic symptom illness? Select all that apply. The client will assume responsibility for self-care activities. The client will identify the relationship between stress and physical symptoms. The client will learn to vary his or her schedule. The client will verbally express emotional feelings. The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings.
The client will assume responsibility for self-care activities. The client will identify the relationship between stress and physical symptoms. The client will verbally express emotional feelings. The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings.
A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. The patient attends anger management classes. Which finding indicates success in this plan of care? a. The patient expresses frustration verbally instead of physically. b. The patient explains the rationale for behaviors to the victim. c. The patient identifies three personal strengths. d. The patient agrees to seek counseling.
The patient expresses frustration verbally instead of physically.
GHB (gamma hydroxybutyric acid), Rohypnol, & Ketamine are drugs associated with sexual assault? True or False
True
For which patient behavior would limit setting be most essential? Clings to the nurse and asks for advice about inconsequential matters. Is flirtatious and provocative with staff members of the opposite sex. Is hypervigilant and refuses to attend unit activities as prescribed. Urges a suspicious patient to hit anyone who stares at them.
Urges a suspicious patient to hit anyone who stares at them.
As part of a follow-up home visit to a client age 80 years who has had surgery, a nurse discusses the client's risk for delirium with his family members. Which of the following would the nurse include as placing the client at increased risk? Select all that apply. a. Urinary tract infection b. Hypertension c. Acute stress d. Advanced age e. Dehydration f. Electrolyte balance
Urinary tract infection Acute stress Advanced age Dehydration Electrolyte balance
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Hypothermia b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo
a. Hypothermia c. Constipation d. Hypotension f. Lanugo
A guest lecturer from a treatment program for perpetrators of abuse is describing the program to a group of nursing students. The program uses cognitive behavioral techniques. Which of the following would the lecturer include as a focus of the program? Select all that apply. a. Identifying what the perpetrator thinks about before the incident b. Determining the perpetrator's emotional & physical responses to the thoughts c. Exploring the perpetrator's actions that eventually lead to violence d. Identifying the behaviors in the survivor that led to the violence e. Determining the extent of guilt or remorse experienced by the perpetrator
a. Identifying what the perpetrator thinks about before the incident b. Determining the perpetrator's emotional & physical responses to the thoughts c. Exploring the perpetrator's actions that eventually lead to violence
People diagnosed with ________________________ frequently use the defense of splitting, which strains personal relationships.
borderline personality disorder
Filling in gaps in memory by fabrication is known as _______________.
confabulation
Clients with ________________________________ have neurologic symptoms that include impaired coordination or balance, paralysis, aphonia (inability to produce sound), difficulty swallowing, a sensation of a lump in the throat, and urinary retention.
conversion disorder (Functional Neurologic Symptom Disorder)
A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client A. displays compulsive and ritualistic behaviors. B. reminisces about the past. C. makes up stories when he is unable to remember actual events. D. refuses to leave home to see a provider.
makes up stories when he is unable to remember actual events.
