TEST ONE: Cognition and Coping review questions

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What information should the nurse give to the family of a client who has had a dissociative episode? A Dissociation is a method for coping with severe stress. B Dissociation suggests the possibility of early dementia. C Brief periods of psychotic behavior may occur. D Ways to intervene to prevent self-mutilation and suicide attempts.

The nurse plans postoperative care for a patient who smokes two packs of cigarettes daily. Which goal should the nurse include in the plan of care for this patient? a. Improve sleep b. Enhance appetite c. Decrease diarrhea d. Prevent sore throat

ANS: A Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are not symptoms associated with nicotine withdrawal.

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

A nurse conducting group therapy on the eating disorders 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

Which behavior would be characteristic of an individual who is displacing anger? a. Lying b. Stealing c. Slapping d. Procrastinating

D (A passive-aggressive person deals with emotional conflict by indirectly and unassertively expressing aggression toward others. Procrastination is an expression of resistance.)

A nurse is caring for a client who has depression and a new prescription for venlafaxine. For which of the following adverse effects should the nurse monitor this client? (Select all that apply.) a. cough b. dizziness c. decreased libido d. alopecia e. hypotension

a, b, c

A young adult invites eight people to dinner. This person has never given a dinner party and wants to prepare every menu item. On the morning of the party, the young adult multitasks and makes progress preparing each food item. As the time approaches for the guests to arrive, which change indicates an increased anxiety level? a. Muscles become tense. The person must stop cooking to use the bathroom every 10 to 15 minutes. b. Blood pressure and pulse rates increase slightly. The person notices feelings of mild muscle tension. c. Fond memories of family reunions and the good food that was served drift in and out of the person's thoughts. d. The person notices there are cobwebs in the corner of the dining room and removes them before the guests arrive.

a. Normal responses to stress and activation of the sympathetic nervous system include muscle tension and frequency or urgency of urination. Other observable symptoms are fine hand tremors, restlessness, nervousness, inability to concentrate, flushing, and sweating. p. 271

A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating a. Undoing b. Projection c. Rationalization d. Reaction formation

d. Reaction formation keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion. p. 274

A symptom commonly associated with panic attacks is a. Obsessions b. Apathy c. Fever d. Fear of impending doom

d. The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is limited severely, and misinterpretation of reality may occur. p. 276

A possible outcome criterion for a client diagnosed with anxiety disorder is a. Client demonstrates effective coping strategies. b. Client reports reduced hallucinations. c. Client reports feelings of tension and fatigue. d. Client demonstrates persistent avoidance behaviors.

A potential problem for a client diagnosed with severe obsessive-compulsive disorder is a. sleep disturbance. b. excessive socialization. c. command hallucinations. d. altered state of consciousness.

A (Clients who must engage in compulsive rituals for anxiety relief are rarely afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep.)

Generally, ego defense mechanisms a. often involve some degree of self-deception. b. are rarely used by mentally healthy people. c. seldom make the person more comfortable. d. are usually effective in resolving conflicts.

A (Most ego defense mechanisms, with the exception of the mature defenses, alter the individual's perception of reality to produce varying degrees of self-deception.)

Inability to leave one's home because of avoidance of severe anxiety suggests the anxiety disorder of a. panic attacks with agoraphobia. b. obsessive-compulsive disorder. c. posttraumatic stress response. d. generalized anxiety disorder.

A (Panic disorder with agoraphobia is characterized by recurrent panic attacks combined with agoraphobia. Agoraphobia involves intense, excessive anxiety about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurred.)

Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr c. Serum potassium 3.4 mEq/L b. Pulse rate 58 beats/min 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/hr. A potassium level of 3.4 mEq/L is within the normal range

Which of the following statements are correct regarding obsessive-compulsive disorder (OCD)? Select all that apply. a. Obsessions are repetitive thoughts, whereas compulsions are ritualistic behaviors. b. OCD symptoms can start as early as 3 years of age. c. OCD patients often have difficulty sleeping. d. Schizophrenia often occurs comorbidly with OCD. e. There is a tool (scale) to measure compulsive behaviors. f. Patients diagnosed with OCD are at higher risk for suicide than patients with depression.

A, B, C, E

Michael seems to be angry when his family fails to visit him in the hospital as promised. However, he tells you that he is fine and that the visit wasn't important to him. When you suggest that perhaps he might be disappointed or even a little angry that the family has again let him down, the patient responds that it is his family that is angry, not him, or else they would have visited. What defense mechanism(s) is this patient using to deal with his feelings? Select all that apply. a. Rationalization b. Projection c. Regression d. Denial e. Dissociation

A, B, D

The symptoms of an adjustment disorder can include characteristics? Select all that apply. a. Guilt b. Social withdrawal c. Overachieving d. Anger e. Depression

A, B, D, E (In contrast to acute stress disorder responses, which are quite severe and include anxiety and fear, symptoms of an adjustment disorder can run the gamut of all forms of distress including guilt, depression, and anger. These feelings may be combined with other manifestations of distress, including physical complaints, social withdrawal, or work or academic inhibition. The behaviors associated with overachieving are not seen in individuals diagnosed with an adjustment disorder.REF: 307)

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.

During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the use of which drug? a. Heroin b. Cocaine c. Tobacco d. Marijuana

ANS: B Inhaled cocaine causes ischemia of the nasal septum, leading to nasal sores and necrosis. These symptoms are not associated with the use of heroin, tobacco, or marijuana.

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.

A patient who smokes a pack of cigarettes daily develops tachycardia and irritability on the second day after abdominal surgery. What is the nurse's best action at this time? a. Escort the patient outside where smoking is allowed. b. Request a prescription for a nicotine replacement agent. c. Tell the patient to calm down and not to think about smoking. d. Ask the patient's family to bring in chewable tobacco products.

ANS: B Nicotine replacement agents should be prescribed for patients who smoke and are hospitalized to avoid withdrawal symptoms. Allowing the patient to smoke or use other tobacco products encourages ongoing tobacco use. Telling the patient to calm down will not relieve withdrawal symptoms.

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

A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. What withdrawal signs does the nurse expect? a. Tremors and seizures b. Vomiting and diarrhea c. Lethargy and disorientation d. Delusions and hallucinations

ANS: B Symptoms of opioid withdrawal include gastrointestinal symptoms such as nausea, vomiting, and diarrhea. The other symptoms are seen during withdrawal from other substances such as alcohol, sedative-hypnotics, or stimulants.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.

ANS: B The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse's action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient's diversional activity deficit. d. The nurse's action assists the patient's integration into community living.

ANS: B The invitation creates a social relationship rather than a therapeutic relationship.

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.

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, relate to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention

A patient who has inhaled cocaine is admitted to the emergency department with palpitations and shortness of breath. What should the nurse do first? a. Infuse normal saline. b. Check oxygen saturation. c. Draw blood for drug screening. d. Obtain a 12-lead echocardiogram (ECG).

ANS: B The priority here is to ensure that oxygenation is adequate. The other orders also should be accomplished as soon as possible but are not the first priority.

Which behavior shows that a nurse values autonomy? The nurse: a. suggests one-on-one supervision for a patient who has suicidal thoughts. b. informs a patient that the spouse will not be in during visiting hours. c. discusses options and helps the patient weigh the consequences. d. sets limits on a patient's romantic overtures toward the nurse.

ANS: C A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

Empathic listening is therapeutic because it focuses on a. enhancing self-esteem. b. lessening feelings of isolation. c. reducing anxiety. d. encouraging resilience.

Empathic listening is therapeutic because it focuses on action? A Enhancing self-esteem B Lessening feelings of isolation C Reducing anxiety D Encouraging resilience

It can be said that the onset of most anxiety disorders occurs a. before the age of 20 years. b. before the age of 40 years. c. after the age of 40 years. d. scattered throughout the life span.

The initial nursing action for a newly admitted anxious client is to a. assess the client's use of defense mechanisms. b. assess the client's level of anxiety. c. limit environmental stimuli. d. provide antianxiety medication.

Which of the following statements about dissociative disorders is true? A Dissociative symptoms are under the person's conscious control. B Dissociative symptoms are not under the person's conscious control. C Dissociative symptoms are usually a cry for attention. D Dissociative symptoms are always negative.

Which statement, made by a client diagnosed with dissociative identity disorder, demonstrates effective understanding in response to the question, "What exactly are the 'alters'? your provider told you about?" illustrates that the education you provided has been effective? A "So, alters are based in mysticism and religiosity, such as demons." B "So, alters are separate personalities with their own characteristics that take over during stress." C "So, alters are never aware of each other." D "So, alters are just like me, but they have no memory of the trauma I went through."

You are caring for Susannah, a 29-year-old who has been diagnosed with dissociative identity disorder. She was recently hospitalized after coming to the emergency room with deep cuts on her arms with no memory of how this occurred. The priority nursing intervention for Susannah is: a. Assist in recovering memories of abuse. b. Maintain 1:1 observation. c. Teach coping skills and stress-management strategies. d. Refer for integrative therapy.

The defense mechanisms that can only be used in healthy ways include a. suppression and humor. b. altruism and sublimation. c. idealization and splitting. d. reaction formation and denial.

B (Altruism and sublimation are known as mature defenses. They cannot be used in unhealthy ways. Altruism results in resolving emotional conflicts by meeting the needs of others, and sublimation substitutes socially acceptable activity for unacceptable impulses.)

What symptom can the nurse expect a client diagnosed with depersonalization disorder to manifest? a. Aimless wandering with confusion and disorientation b. A feeling of detachment from one's body or mental processes c. Existence of two or more personalities that take control of behavior d. Worry about having a serious disease based on symptom misinterpretation

B (Depersonalization is characterized by a sense of unreality or self-estrangement. None of the other options present an expected characteristic of depersonalization disorder.REF: Page 296-297)

Empathic listening is therapeutic because it focuses on action? a. Enhancing self-esteem b. Lessening feelings of isolation c. Reducing anxiety d. Encouraging resilience

B (Empathic listening can be healing because it can help minimize feelings of isolation. Empathic listening is not focused on any of the other factors suggested by the other options.REF: 311; Table 16-2)

What can be said about the comorbidity of anxiety disorders? a. Anxiety disorders generally exist alone. b. A second anxiety disorder may coexist with the first. c. Anxiety disorders virtually never coexist with mood disorders. d. Substance abuse disorders rarely coexist with anxiety disorders.

B (In many instances, when one anxiety disorder is present, a second one coexists. Clinicians and researchers have clearly shown that anxiety disorders frequently co-occur with other psychiatric problems. Major depression often co-occurs and produces a greater impairment with poorer response to treatment.)

Which therapeutic intervention can the nurse implement personally to help a client diagnosed with a mild anxiety disorder regain control? a. Flooding b. Modeling c. Thought stopping d. Systematic desensitization

B (Modeling calm behavior in the face of anxiety or unafraid behavior in the presence of a feared stimulus are interventions that can be independently used. The other options require agreement of the treatment team.)

An obsession is defined as a. thinking of an action and immediately taking the action. b. a recurrent, persistent thought or impulse. c. an intense irrational fear of an object or situation. d. a recurrent behavior performed in the same manner.

B (Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind.)

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? a. Overeating b. Hypervigilance c. A drive to be perfect d. Passivity

B (PTSD in preschool children may manifest as irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance. None of the other options are characteristic of PTSD in a young child.REF: 296

A 20-year-old was sexually molested at age 10, but he can no longer remember the incident. The ego defense mechanism in use is a. projection. b. repression. c. displacement. d. reaction formation.

B (Repression is a defense mechanism that excludes unwanted or unpleasant experiences, emotions, or ideas from conscious awareness.)

The nurse anticipates that the nursing history of a client diagnosed with obsessive compulsive disorder (OCD) will reveal a. a history of childhood trauma. b. a sibling with the disorder. c. an eating disorder. d. a phobia as well.

B (Research shows that first-degree biological relatives of those with OCD have a higher frequency of the disorder than exists in the general population.)

Studies of clients diagnosed with posttraumatic stress disorder suggest that the stress response of which of the following is considered abnormal? a. Brainstem b. Hypothalamus-pituitary-adrenal system c. Frontal lobe d. Limbic system B (Studies of clients with posttraumatic stress disorder suggest that the stress response of the hypothalamus-pituitary-adrenal system is abnormal.)

B (Studies of clients with posttraumatic stress disorder suggest that the stress response of the hypothalamus-pituitary-adrenal system is abnormal.)

An important question to ask during the assessment of a client diagnosed with anxiety disorder is a. "How often do you hear voices?" b. "Have you ever considered suicide?" c. "How long has your memory been bad?" d. "Do your thoughts always seem jumbled?"

B (The presence of anxiety may cause an individual to consider suicide as a means of finding comfort and peace. Suicide assessment is appropriate for any client with higher levels of anxiety.)

A child who is able to regain mental stability after a traumatic event is said to be demonstrating what trait? a. Autonomy b. Resilience c. Maturity d. Independence

B (The term resilience refers to positive adaptation, or the ability to maintain or regain mental health despite adversity. None of the other terms suggest such an ability.REF: 298-299)

Selective inattention is first noted when experiencing anxiety that is a. mild. b. moderate. c. severe. d. panic.

B (When moderate anxiety is present, the individual's perceptual field is reduced and the client is not able to see the entire picture of events.)

A child who is able to regain mental stability after a traumatic event is said to be demonstrating what trait? A Autonomy B Resilience C Maturity D Independence

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next? A. Beta blocker B. Barbiturate C Tricyclic antidepressant (TCA) D Sedative

Ashley is a 21-year-old college student who was sexually assaulted at a party. She was seen in the local emergency department and referred for counseling after being diagnosed by the provider on call as having acute stress disorder. Which of the following treatment modalities would you expect to see used in therapy with Ashley? a. Aversion therapy b. Stress-reduction therapy c. Cognitive-behavioral therapy d. Short-term classical analysis therapy

Dissociative identity disorder is characterized by what event? A The inability to recall important information B Sudden, unexpected travel away from home and inability to remember the past C The existence of two or more subpersonalities, each with its own patterns of thinking D Recurring feelings of detachment from one's body or mental processes

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. Which response should the nurse provide to best address the parent's concerns? A Children of this age usually have imaginary friends. B It is nothing to worry about unless the child starts to socially isolate. C The child needs more of their one-on-one attention. D The imaginary friend is a coping mechanism the child is using.

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? A A 13-year-old male B A 10-year-old female C A 7-year-old male D A 4-year-old female

You are caring for Connor, an 8-year-old boy who has been diagnosed with reactive attachment disorder. Which of the following nursing outcomes would be the most appropriate to achieve? a. Increases ability to self-control and decreases impulsive behaviors. b. Avoids situations that trigger conflicts. c. Expresses complex thoughts.d. Writes or draws feelings in a journal.

In a teaching session, the nurse uses strategies that would induce a slight degree of anxiety in the patients attending the session. What is the nurse's intention for this action? a. The patients would be more focused during the session. b. The patients would be more expressive during the session. c. The patients would be more comfortable during the session. d. The patients would be more willing to participate in the session.

a Mild anxiety causes patients to see, listen, and grasp more information. This helps the patients to focus more on whatever is taught during the teaching session. Mild anxiety is unlikely to improve the patient's expression, comfort level, or willingness to participate. The nurse should involve the patient in discussion so that the patient expresses his or her feelings and should modify the environment of teaching to make the patient comfortable. p. 271

A disorder in which one experiences fear of being in places or situations from which escape might be difficult or embarrassing or in which help might not be available if a panic attack occurs is called ____________________.

agorophobia

A 3-year-old child is admitted for an extensive stay in an acute care hospital. The parents will be able to visit only on weekends. The nurse bases emotional care of the child on the understanding that a. Children are emotionally resilient at this age b. The nursing staff can act as effective substitutes for the child's parents c. The child is at risk for physical illnesses resulting from the separation d. Providing appropriate stimulating activities will minimize the child's stress-related risks

c. Children who have been separated from their mothers, especially if placed in an impersonal environment, show a decline in physical health. Resiliency will not be sufficient to overcome the effects of separation from parents. The nursing staff may attempt to be substitutes for the parents, but at this age, the child will be aware of the separation and experience the negative effects. Stimulation will address cognitive and development needs but not emotional ones. p. 273

A new patient is diagnosed with generalized anxiety disorder. It is most important for the nurse to assess this patient for which additional problem? a. Conduct disorder b. Alcohol use disorder c. Major depressive disorder d. Obsessive-compulsive disorder

c. Clinicians and researchers have shown clearly that anxiety disorders frequently co-occur with other psychiatric problems. Several studies suggest that other psychiatric disorders coexist about 90% of the time in people with generalized anxiety or panic disorder. Anxiety disorders are comorbid with major depression at a rate of 60%; in this type of comorbidity, anxiety symptoms tend to happen before depressive symptoms. While conduct disorder, alcohol use disorder, and obsessive-compulsive disorder are possibilities, the most likely comorbid problem is depression. p 282

A student nurse observes that a patient often looks at her reflection in the mirror. What is the most appropriate diagnosis the student nurse could make from the patient's behavior? a. The patient has panic disorder. b. The patient has hoarding disorder. c. The patient has body dysmorphic disorder. d. The patient has obsessive-compulsive disorder.

c. Dysmorphic disorders are characterized by a preoccupation with an imagined defective body part. Dysmorphic patients often pay excessive attention to body parts that they imagine to be defective. As a result, they may develop obsessive-compulsive behaviors such as often checking the mirrors. In obsessive-compulsive disorder patients perform repeated activities or rituals. In hoarding disorder the patient accumulates and collects all materials for future use. Patients with panic disorder may have an unusual fear of future events. p. 280

A nurse conducts a clinical interview with children to assess types of anxiety. Which scale does the nurse use to measure phobias present in the children? a. Yale-Brown obsessive-compulsive scale b. Hoarding scale self-report c. Fear questionnaire d. Panic disorder severity scale

c. Fear questionnaire is used to measure phobias present in the patients. The patients are questioned about the different types of fear which they experience. The rating is given according to the intensity. Yale-Brown obsessive-compulsive scale is used to measure the severity of compulsive behavior. Hoarding scale self-report is used to measure hoarding in a patient. Panic disorder severity scale is used to measure panic symptoms. p. 282

To support best improvement in an anxious individual's sense of control and competence, the nurse: a. Provides lavish amounts of praise when the individual accomplishes assigned tasks. b. Educates the individual regarding the usefulness of stress management techniques. c. Helps the individual identify several stress situations that he or she was successful in managing. d. Has the individual describe how one demonstrates control and competence over stress.

c. Positive self-concepts result from positive experiences, leading to perceived competence and acceptance. Assisting the patient in identifying such situations will aid in building confidence and one's perception of being competent. Being praised for successes is appropriate, but it must be reserved for situations that the individual recognizes as meaningful. Although stress management techniques are important, they are not linked directly to a sense of competence. Describing how one demonstrates control and competence is applicable but it has limited favor in actually assisting the patient in feeling competent. p. 285

Nick, a construction worker, is on duty when a nearly completed wall suddenly falls, crushing a number of co-workers. Although badly shaken initially, he seemed to be coping well. About two weeks after the tragedy he begins to experience tremors, nightmares, and periods during which he feels numb or detached from his environment. He finds himself frequently thinking about the tragedy and feeling guilty that he was spared while many others died. Which statement about this situation is most accurate? a. Nick has acute stress disorder and will benefit from antianxiety medications. b. Nick is experiencing posttraumatic stress disorder (PTSD) and should be referred for outpatient treatment. c. Nick is experiencing anxiety and grief and should be monitored for PTSD symptoms. d. Nick is experiencing mild anxiety and a normal grief reaction; no intervention is needed.

A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." A helpful response for the nurse to make would be a. "What things have you done in the past that helped you feel more comfortable?" b. "Let's try to focus on that adorable little granddaughter of yours." c. "Why don't you sit down over there and work on that jigsaw puzzle?" d. "Try not to think about the feelings and sensations you're experiencing."

A (Because the client is not able to think through the problem and arrive at an action that would lower anxiety, the nurse can assist by asking what has worked in the past. Often what has been helpful in the past can be used again.)

What information should the nurse give to the family of a client who has had a dissociative episode? a. Dissociation is a method for coping with severe stress. b. Dissociation suggests the possibility of early dementia. c. Brief periods of psychotic behavior may occur. d. Ways to intervene to prevent self-mutilation and suicide attempts.

A (Childhood physical, sexual, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms. None of the other options are true.REF: 297-298)

When discussing the symptoms of post-traumatic stress disorder (PTSD), the nurse should make which statement? a. "The symptoms can occur almost immediately or can take years to manifest." b. "PTSD causes agitation and hypervigilance but rarely chronic depression." c. "When experiencing a flashback, the client generally experiences a slowing of responses." d. "PTSD is an emotional response that does not cause significant changes in brain chemistry."

A (The onset of PTSD symptoms can occur as early as a month after exposure, but a delay of months or years is not uncommon. None of the other statements correctly describe the symptoms of PTSD.)

Which statement about structural dissociation of the personality is true? a. An organic basis exists for this type of disorder. b. Nurses perceive clients with this disorder as easy to care for. c. No known link exists between this disorder and early childhood loss or trauma. d. This disorder results in a split in the personality causing a lack of integration.

A (The theory of structural dissociation of the personality proposes that patients with complex trauma have different parts of their personality, the apparently normal part and the emotional part, that are not fully integrated with each other. Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors. These different parts may not be aware of each other, with only one dominant personality operating depending on the situation and circumstance of the moment. None of the other options are accurate statements regarding this disorder.REF: 307)

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a. Begin at the orientation phase. b. Resume the working relationship. c. Initially establish a social relationship. d. Return to the emotional catharsis phase.

ANS: A After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window. Which nursing diagnosis should the nurse assign as the highest priority? a. Risk for injury related to altered perception b. Ineffective coping related to situational issues c. Ineffective health maintenance related to drug use d. Powerlessness related to loss of behavioral control

ANS: A Although all the diagnoses may be appropriate for the patient, the highest priority is to address the patient's immediate risk for injury.

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a. "How do you feel about that?" b. "I am glad that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"

ANS: A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

A young adult patient scheduled for an annual physical examination arrives in the clinic smelling of cigarette smoke and carrying a pack of cigarettes. Which action will the nurse plan to take? a. Urge the patient to quit smoking as soon as possible. b. Avoid confronting the patient about smoking at this time. c. Wait for the patient to start a discussion about quitting smoking. d. Explain that the "cold turkey" method is most effective in stopping smoking.

ANS: A Current national guidelines indicate that health care professionals should urge patients who smoke to quit smoking at every encounter. The other actions will not help decrease the patient's health risks related to smoking.

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

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.

A newly admitted patient complains of waking frequently during the night. The nurse observes the patient wearing a nicotine patch on the right upper arm. Which action should the nurse take first? a. Question the patient about use of the patch at night. b. Suggest that the patient go to bed earlier in the evening. c. Ask the health care provider about prescribing a sedative drug for nighttime use. d. Remind the patient that the benefits of the patch outweigh the short-term insomnia.

ANS: A Insomnia can occur when nicotine patches are used all night. This can be resolved by removing the patch in the evening. The other actions may be helpful in improving the patient's sleep, but the initial action should be to ask about nighttime use of the patch and suggest removal of the patch at bedtime.

Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, "I am using contraceptives." c. says, "I feel full after eating a small meal." d. reports problems with dry mouth and constipation.

ANS: A Lorcaserin is designed to make people feel full after eating smaller meals by activating a serotonin 2c receptor in the brain and blocking appetite signals. According to the FDA, this drug should be stopped if a patient does not have 5% weight loss after 12 weeks of use. If the patient now weighs 196 pounds, the medication has not been effective. The distracters indicate patient learning was effective and expected side effects of this medication.

One bed is available on the inpatient eating disorders 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 within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patient's transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

ANS: A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient's expression of gratitude.

A patient who has a history of ongoing opioid use is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication will the nurse administer? a. Naloxone b. Diazepam (Valium) c. Clonidine (Catapres) d. Methadone (Dolophine)

ANS: A The patient's assessment indicates an opioid overdose, and naloxone should be given to prevent respiratory arrest. The other medications may be used to decrease symptoms associated with opioid withdrawal but would not be appropriate for an overdose.

A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use? a. "I am older and wiser now, and I can change my drinking behavior." b. "Alcohol has never bothered my stomach before. I think I have the flu." c. "People say that I drink too much, but I feel pretty good most of the time." d. "My drinking is affecting my stomach, but medication will help me feel better."

ANS: A The statement "I am older and wiser now, and I can change my drinking behavior" indicates the patient expresses willingness to stop alcohol use and an initial commitment to changing alcohol intake behaviors. In the remaining statements, the patient recognizes that alcohol use is the reason for the gastritis but is not yet willing to make a change.

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.

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

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a. boundary blurring. c. positive regard. b. sexual harassment. d. advocacy.

ANS: A When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

The nurse is reviewing the care plan for a patient experiencing difficulty coping with stress. The nurse recognizes that an example of initiating a cognitive restructuring intervention to enhance coping abilities is known as which of the following? a. Identifying the cause of fear b. Accessing a community support group c. Identifying relaxation methods d. Reviewing an educational pamphlet

ANS: A Identifying the cause of a negative perception is the first step in restructuring how a patient perceives a stressor, also called cognitive restructuring. Accessing a community support group is an example of accessing resources to enhance coping. Identifying relaxation methods is an example of developing an action plan. Reviewing an educational pamphlet is an example of using education to enhance coping.

The nurse teaches a patient who is experiencing stress at work how to use imagery as a relaxation technique. Which statement by the nurse would be appropriate? a. "Think of a place where you feel peaceful and comfortable." b. "Place the stress in your life into an image that you can destroy." c. "Repeatedly visualize yourself experiencing the distress in your workplace." d. "Bring what you hear and sense in your work environment into your image."

ANS: A Imagery is the use of one's mind to generate images that have a calming effect on the body. When using imagery for relaxation, the patient should visualize a comfortable and peaceful place. The goal is to offer a relaxing retreat from the actual work environment. Imagery that is not intended for relaxation purposes can target a disease, problem, or stressor.

A patient who is taking antiretroviral medication to control human immunodeficiency virus (HIV) infection tells the nurse about feeling mildly depressed and anxious. Which additional information about the patient is most important to communicate to the health care provider? a. The patient takes vitamin supplements and St. John's wort. b. The patient recently experienced the death of a close friend. c. The patient's blood pressure has increased to 152/88 mm Hg. d. The patient expresses anxiety about whether the drugs are effective.

ANS: A St. John's wort interferes with metabolism of medications that use the cytochrome P450 enzyme system, including many HIV medications. The health care provider will need to check for toxicity caused by the drug interactions. Teaching is needed about drug interactions. The other information will also be reported but does not have immediate serious implications for the patient's health.

A patient is the primary caregiver for a disabled family member at home, and has now been unexpectedly hospitalized for surgery. What action can the nurse take to enhance the coping ability of the patient? a. Ask if there is another family member who can help at home while the patient is in the hospital. b. Plan to transfer the patient to a rehabilitation unit after surgery to allow uninterrupted time to recover. c. Coordinate an ambulance transfer of the family member to an alternate family member's home. d. Ask social services to assess what the patient's needs will be after discharge to home.

ANS: A The best action by the nurse is to help the patient develop an action plan to assess what resources may already be available to meet responsibilities at home. A long absence from the home on a rehabilitation unit does not address the immediate need to provide care for the disabled family member. An ambulance transfer to another family member is premature until the placement is identified as an appropriate placement based on the disabled person's needs, availability to provide the care by another, and distance of the transfer. Assessing the patient's needs after discharge does not address the immediate need to provide care for the disabled family person. REF: Page 312

An adult patient who is hospitalized after a motorcycle crash tells the nurse, "I didn't sleep last night because I worried about missing work at my new job and losing my insurance coverage." Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety b. Defensive coping c. Ineffective denial d. Risk prone health behavior

ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient.

A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective Coping related to hospitalization c. Denial related to hospitalization d. High Risk for Insomnia related to hospitalization

ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient's data do not support Defensive Coping, Ineffective Denial, or Risk-Prone Health Behavior as problems for this patient.

A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. "What kinds of things do you do to reduce or cope with your stress?" b. "Tell me about your family history—do any relatives have problems with stress?" c. "Tell me about exercise—how far do you typically run when you go jogging?" d. "Stress can interfere with sleep. How much did you sleep last night?"

ANS: A The most important data to collect during an initial assessment is that which reflects how stress is affecting the patient and how he is coping with stress at present. This data would indicate whether his distress is placing him in danger (e.g., by elevating his blood pressure dangerously or via maladaptive responses such as drinking) and would help you understand how he copes and how well his coping strategies and resources are serving him. Therefore, of the choices presented, the highest priority would be to determine what he is doing to cope at present, preferably via an open-ended or broad-opening inquiry. Family history, the extent of his use of exercise, and how much sleep he is getting are all helpful but seek data that is less of a priority. Also, the manner in which such data is sought here is likely to provide only brief responses (e.g., how much sleep he got on one particular night is probably less important than how much he is sleeping in general).

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialogues with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient to identify strengths, limitations, and problems.

ANS: A, B The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases.

The nurse is assessing the coping patterns of a newly admitted patient. What will the nurse include in this assessment? (Select all that apply.) a. Current stressors as perceived by the patient b. Use of drugs or alcohol c. Recent weight changes d. Age and height e. Temperature

ANS: A, B, C Stressors are subjective based on patient perception and assessment of stressors as part of a patient history. Stressors trigger coping behaviors that can include negative uses of drugs and alcohol and appetite changes that affect weight. Age, height, and temperature are not typically altered with coping, although pulse, respiratory rate, and blood pressure may be affected.

The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Pancreatitis c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism

ANS: A, C, D, E, F Cancer, COPD, dysrhythmias, encephalitis, hypothyroidism, and hyperthyroidism are all associated with anxiety. Pancreatitis is not listed as a condition most commonly associated with anxiety.

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. See relationship to audience response question.

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d. The nurse should begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

ANS: A, E The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse's relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

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 compliance with treatment. 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.

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. "This patient continues to deny problems resulting from drinking." b. "My parents were alcoholics and often neglected our family." c. "The patient cannot identify any goals for improvement." d. "The patient said I have many traits like her mother."

ANS: B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse's irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient's behavior.

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

A nurse wants to enhance growth of a patient by showing positive regard. The nurse's action most likely to achieve this goal is: a. making rounds daily. b. staying with a tearful patient. c. administering medication as prescribed. d. examining personal feelings about a patient.

ANS: B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse's ability to be therapeutic.

A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg, heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important? a. Reorient the patient at frequent intervals. b. Monitor the patient's electrocardiogram (ECG). c. Keep the patient in a quiet and darkened room. d. Obtain a health history including prior drug use.

ANS: B The priority is to ensure physiologic stability given that methamphetamine use can lead to complications such as myocardial infarction. The other actions are also appropriate but are not of as high a priority.

A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the medication orders, which drug should the nurse administer first? a. Oral multivitamin daily b. Thiamine (vitamin B1) 100 mg daily c. Lorazepam (Ativan) 1 mg as needed d. Folic acid (Vitamin B9) 0.4 mg daily

ANS: B Thiamine is given to all patients with alcohol intoxication to prevent Wernicke's encephalopathy. Because Wernicke's encephalopathy can be precipitated by the administration of glucose solutions, thiamine should be given before or concurrently with a dextrose solution. Lorazepam would not be appropriate while the patient still has an elevated BAC. Folic acid may also be administered but is not as important as thiamine.

A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.

ANS: B Efficacy may take at least 8 to 12 weeks. The other options are not realistic.

The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.

ANS: B High-quality social support enhances mental and physical health and acts as a significant buffer against distress. Low-quality support relationships are known to affect a person's coping effectiveness negatively. Resuming dating soon after a divorce could place additional stress on the patient rather than helping them cope with existing stressors. Developing relationships on the Internet probably would not substitute fully for direct contact with other humans and could expose the patient to predators misrepresenting themselves to take advantage of vulnerable persons.

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child?" b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."

ANS: B Mindfulness trains the mind to think in the here and now, and emphasizes attentiveness to all sensations and feelings related to these experiences. Recalling and remembering being calm or previous experiences is not included in mindfulness training. Eye movement desensitization and reprocessing (EMDR) includes expression of feelings and memories while focusing on other stimuli such as sounds, hand taps, and/or eye movements.

An adult patient who arrived at the triage desk in the emergency department (ED) with minor facial lacerations after a motor vehicle accident has a blood pressure (BP) of 182/94. Which action by the nurse is appropriate? a. Start an IV line to administer antihypertensive medications. b. Recheck the blood pressure after the patient has been assessed. c. Discuss the need for hospital admission to control blood pressure. d. Teach the patient about the stroke risk associated with uncontrolled hypertension.

ANS: B When a patient experiences an acute stressor, the BP increases. The nurse should plan to recheck the BP after the patient has stabilized and received treatment. This will provide a more accurate indication of the patient's usual blood pressure. Elevated BP that occurs in response to acute stress does not increase the risk for health problems such as stroke, indicate a need for hospitalization, or indicate a need for IV antihypertensive medications.

Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a. Encouraging a patient to share initial impressions of staff b. Having the same nurse care for a patient on a daily basis c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patient's problems

ANS: B, C, D Consistency implies predictability. Having the same nurse see the patient daily and provide a daily schedule of patient activities and a set time for regular sessions will help a patient predict what will happen during each day and develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention.

The nurse wishes to use guided imagery to help an anxious patient relax. Which comment would be appropriate to include in the guided imagery script? (Select all that apply.) a. "Imagine others treating you the way they should, the way you want to be treated..." b. "With each breath, you are feeling calmer, more relaxed, almost as if you are floating..." c. "You are alone on a beach; the sun is warm; and you hear only the sound of the surf..." d. "You have taken control; nothing can hurt you now; everything is going your way..." e. "You have grown calm; your mind is still; there is nothing to disturb your well-being..." f. "You will feel better as work calms down, as your boss becomes more understanding..."

ANS: B, C, E The intent of guided imagery for managing stress is to lead the patient to envision images that are calming and health enhancing. Statements that involve the patient calming progressively with breathing, feeling increasingly relaxed, being in a calm and pleasant location, being away from stressors, and having a peaceful and calm mind are therapeutic and should be included in the script. However, words that raise stressful images or memories or that involve unrealistic expectations or elements beyond the patient's control (e.g., that others will treat the patient as he desires, that everything is going the patient's way, that bosses are understanding) interfere with relaxation and/or do not promote effective coping. These attempts are not health promoting and should not be included in the script.

A patient who is hospitalized with a pelvic fracture after a motor vehicle accident just received news that the driver of the car died from multiple injuries. What actions should the nurse take based on knowledge of the physiologic stress reactions that may occur in this patient (select all that apply)? a. Assess for bradycardia. b. Observe for decreased appetite. c. Ask about epigastric discomfort. d. Monitor for decreased respiratory rate. e. Check for elevated blood glucose levels.

ANS: B, C, E The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and increase blood glucose levels. In addition, stress causes an increase in respiratory and heart rates.

A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal? Select all that apply. a. Sitting behind a desk, facing the patient b. Introducing self to a patient and identifying own role c. Maintaining control of discussions by asking direct questions d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

ANS: B, D, E Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse's verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort.

Which information is most important for the nurse to report to the health care provider about a patient who has been using varenicline (Chantix)? a. The patient continues to smoke a few cigarettes every day. b. The patient complains of headaches that occur almost daily. c. The patient complains of new-onset sadness and depression. d. The patient says, "I have decided that I am not ready to quit."

ANS: C Adverse effects of varenicline include depression and attempted suicide. The patient's symptoms require immediate assessment and discontinuation of the drug. The other information will also be reported, but it does not indicate any life-threatening problems associated with the medication.

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.

A 73-yr-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment? a. Mini-Mental State Examination b. Drug Abuse Screening Test (DAST-10) c. Screening Test-Geriatric Version (SMAST-G) d. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

ANS: C Because alcohol use is a common factor associated with the development of pancreatitis, the first assessment step is to screen for alcohol use using a validated screening questionnaire. The SMAST-G is a short-form alcoholism screening instrument tailored specifically to the needs of the older adult. If the patient scores positively on the SMAST-G, then the CIWA-Ar would be a useful tool for determining treatment. The DAST-10 provides more general information regarding substance use. The Mini-Mental State Examination is used to screen for cognitive impairment.

A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center.

ANS: C Encopresis refers to unsuccessful bowel control. Bowel control is expected by age 5, so frequent involuntary defecation is associated with this diagnosis. Smearing feces is behavioral. Enuresis refers to the voiding of urine during the day (diurnal) or at night (nocturnal)

A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. 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

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a. "Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. "That's a good topic for you to discuss with your doctor." d. "Do you think you can't speak to a doctor?"

ANS: C Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency.

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

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. See relationship to audience response question

An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. What will the nurse expect the patient to need during the perioperative period? a. An increased dose of the general anesthetic medication b. Interventions to prevent withdrawal symptoms within 2 hours c. Frequent monitoring for bleeding and respiratory complications d. Stimulation every hour to prevent prolonged postoperative sedation

ANS: C Patients who are intoxicated at the time of surgery are at increased risk for problems with bleeding and respiratory complications such as aspiration. In an intoxicated patient, a lower dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is likely to occur later in the postoperative course because the medications used for anesthesia, sedation, and pain will delay withdrawal symptoms. The patient should be monitored frequently for oversedation but does not need to be stimulated.

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

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

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches 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

A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells the nurse, "I am just not ready to quit smoking yet." Which response by the nurse is appropriate for the patient's stage of change? a. "This would be a really good time to quit." b. "Your smoking is the cause of your chest pain." c. "Are you familiar with nicotine replacement products?" d. "What health problems do you think smoking has caused?"

ANS: C The patient is in the precontemplation stage of change, and the nurse's role is to assist the patient to become motivated to quit. The current Clinical Practice Guidelines indicate that the nurse should ask the patient to identify any negative consequences from smoking. The responses "This would be a really good time to quit" and "Your smoking is the cause of your chest pain" express judgmental feelings by the nurse and are not likely to motivate the patient. Providing information about the various nicotine replacement options would be appropriate for a patient who has expressed a desire to quit smoking.

A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is appropriate? a. Encourage increased oral intake. b. Insert an IV line and infuse fluids. c. Provide a quiet, well-lit environment. d. Administer opioids to provide sedation.

ANS: C The patient's symptoms suggest acute alcohol withdrawal, and a quiet and well-lit environment will help decrease agitation, delusions, and hallucinations. There is no indication that the patient is dehydrated. Benzodiazepines, rather than opioids, are used to prevent withdrawal. IV lines are avoided whenever possible.

After receiving change-of-shift report on four patients who are undergoing substance use treatment, which patient will the nurse assess first? a. A patient who has just arrived for alcohol use treatment and states that the last drink was 2 hours ago b. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago d. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/min

ANS: C The patient's tremors indicate risk for seizures and possible cardiac/respiratory arrest, which can occur with withdrawal from sedative-hypnotics. The greatest risk for these complications is during days three to five after stopping the drug. Opioid and stimulant withdrawal are uncomfortable but not life threatening. Symptoms of alcohol withdrawal do not occur until 4 to 6 hours after the last drink.

The school nurse is assessing coping skills of high school students who attend an alternative school for students at high risk to not graduate. What is the priority concern that the nurse has for this student population? a. Altered vital sign readings b. Inaccurate perceptions of stressors c. Increased risk for suicide d. Decreased access to alcoholic beverages

ANS: C Adolescents with poor coping have increased risk for drug and alcohol use, risky sexual behaviors, and suicide. Pulse, respiratory rate, and blood pressure may change during stress, but patient safety is the priority concern. Adolescents may have inaccurate perceptions of stressors, and this actually increases the risk for unsafe behaviors. Adolescents under stress are more at risk for increasing their access to alcohol and illegal drugs.

A nurse prepares an adult patient with a severe burn injury for a dressing change. The nurse knows that this is a painful procedure and wants to try providing music to help the patient relax. Which action is best for the nurse to take? a. Use music composed by Mozart. b. Play music that does not have words. c. Ask the patient about music preferences. d. Select music that has 60 to 80 beats/minute.

ANS: C Although music with 60 to 80 beats/min, music without words, and music composed by Mozart are frequently recommended to reduce stress, each patient responds individually to music and personal preferences are important.

A female patient who initially came to the clinic with incontinence was recently diagnosed with endometrial cancer. She is usually well organized and calm, but the nurse who is giving her preoperative instructions observes that the patient is irritable, has difficulty concentrating, and yells at her husband. Which action should the nurse take? a. Ask the health care provider for a psychiatric referral. b. Focus teaching on preventing postoperative complications. c. Try to calm the patient before repeating any information about the surgery. d. Encourage the patient to combine the hysterectomy with surgery for bladder repair.

ANS: C Because behavioral responses to stress include temporary changes such as irritability, changes in memory, and poor concentration, patient teaching will need to be repeated. It is also important to try to calm the patient by listening to her concerns and fears. Psychiatric referral will not necessarily be needed for her but that can better be evaluated after surgery. Focusing on postoperative care does not address the need for preoperative instruction such as the procedure, NPO instructions before surgery, date and time of surgery, medications to be taken or discontinued before surgery, and so on. The issue of incontinence is not immediately relevant in the discussion of preoperative teaching for her hysterectomy.

After a management decision to admit terminal care patients to a medical unit, the nursing manager notes that nursing staff on the unit appear tired and anxious. Staff absences from work are increasing. The nurse manager is concerned that staff may be experiencing stress and burnout at work. What action would be best for the manager to take that will help the staff? a. Ask administration to require staff to meditate daily for at least 30 minutes. b. Have a staff psychologist available on the unit once a week for required counseling. c. Have training sessions to help the staff understand their new responsibilities. d. Ask support staff from other disciplines to complete some nursing tasks to provide help.

ANS: C Feeling unprepared for work responsibilities contributes to stress and poor coping in the workplace. Administration cannot require that staff participate in meditation or counseling sessions, although these can be recommended and encouraged. Asking other disciplines to assume nursing tasks is not appropriate for their scope of practice

The nurse is developing a care plan for a patient with ineffective coping skills. Which intervention would be an example of a problem-focused coping strategy? a. Scheduling a regular exercise program b. Attending a seminar on treatment options c. Identifying a confidant to share feelings d. Attending a support group for families

ANS: C Problem-focused strategies are used to find solutions or improvement to the underlying stressor, such as accessing community resources or attending educational seminars. Exercise, emotional support, and support groups are emotion-based strategies that create a feeling of well-being.

A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching b. Guided imagery c. Relaxation breathing d. Mindfulness meditation

ANS: C Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagery require more time to practice and learn.

A patient who has frequent migraines tells the nurse, "My life feels chaotic and out of my control. I could not manage if anything else happens." Which response should the nurse make initially? a. "Regular exercise may get your mind off the pain." b. "Guided imagery can be helpful in regaining control." c. "Tell me more about how your life has been recently." d. "Your previous coping resources can be helpful to you now."

ANS: C The nurse's initial strategy should be further assessment of the stressors in the patient's life. Exercise, guided imagery, or understanding how to use coping strategies that worked in the past may be of assistance to the patient, but more assessment is needed before the nurse can determine this.

A hospitalized patient with diabetes tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up. This is so frustrating." Which response by the nurse is accurate? a. "The liver is not able to metabolize glucose as well during stressful times." b. "Your diet at the hospital is the most likely cause of the increased glucose." c. "The stress of illness causes release of hormones that increase blood glucose." d. "It is probably coincidental that your blood glucose is higher when you are ill."

ANS: C The release of cortisol, epinephrine, and norepinephrine increase blood glucose levels. The increase in blood glucose is not coincidental. The liver does not control blood glucose. A patient with diabetes who is hospitalized will be on an appropriate diet to help control blood glucose.

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

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

Which assessment finding would alert the nurse to ask the patient about alcohol use? a. Low blood pressure b. Decreased heart rate c. Elevated temperature d. Abdominal tenderness

ANS: D Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with chronic alcohol use. The other problems are not associated with alcohol use.

After the nurse receives report, which patient should the nurse assess first? a. Patient who has a respiratory rate of 14 after overdosing on oxycodone (OxyContin) b. Patient who is experiencing hallucinations and extreme anxiety after the use of marijuana c. Patient with a history of daily alcohol use who is complaining of insomnia and diaphoresis d. Patient admitted with cocaine use who has an irregular heart rate of 142 beats/minute and BP 186/92 mm Hg

ANS: D Because the patient with cocaine use has symptoms suggestive of a possible fatal dysrhythmia, this patient should be assessed immediately. The other patients should also be seen as soon as possible, but their clinical manifestations do not suggest that life-threatening complications may be occurring.

Which nursing activity can the nurse delegate to unlicensed assistive personnel (UAP) who are working in a family practice clinic? a. Make referrals to community substance use treatment centers. b. Teach patients about the use of prescribed nicotine replacement products. c. Obtain patient histories regarding alcohol, tobacco, and other substance use. d. Administer and score the Alcohol Use Disorders Identification Test (AUDIT).

ANS: D No clinical judgment is needed to administer the AUDIT, which is a written questionnaire that is given to patients for self-administration and scored based on patient answers. Making appropriate referrals, patient teaching, and obtaining a patient history all require critical thinking and RN education and scope of practice.

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

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 attempts to question the patient's distorted thinking

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.

ANS: D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings.

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

A 25-yr-old patient comes to the emergency department with severe chest pain and agitation. Which action should the nurse take first? a. Ask about use of stimulant drugs. b. Start an IV for sedative administration. c. Assess orientation to person, place, and time. d. Check blood pressure, pulse, and respirations.

ANS: D The patient has symptoms consistent with the use of cocaine or amphetamines and is at risk for fatal tachydysrhythmias or complications of hypertension such as stroke or myocardial infarction. The nurse also will ask about drug use and assess orientation, but these are not the priority actions. Naloxone may be given if the patient develops symptoms of central nervous system depression, but this patient's current symptoms indicate stimulant use.

An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response by the nurse is best? a. "The prescription cannot be refilled for another month. What happened to all of your pills?" b. "Do you have muscle cramps and tremors if you don't take the medication frequently?" c. "I will ask the health care provider to prescribe more pills, but you will not be able to have them until next month." d. "I am concerned that you may be overusing those. Let's make an appointment for you with the health care provider."

ANS: D The patient should be assessed for problems that are causing overuse of alprazolam, such as anxiety or memory loss. The other responses by the nurse will not allow for the needed assessment and possible referral for support services or treatment of drug dependence.

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.

A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%). Which action by the nurse is appropriate? a. Restrict oral and IV fluids. b. Maintain the patient on NPO status. c. Administer acetaminophen for headache. d. Monitor for hyperreflexia and diaphoresis.

ANS: D The patient's assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyperreflexia, and sweating, which could be life threatening. Acetaminophen is not recommended because it is metabolized by the liver. Alcohol has a dehydrating effect so fluids should not be restricted and there is no indication that the patient should be NPO.

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

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. 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.

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is correct. d. Differing values are reflected in the two statements.

ANS: D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

The nurse has been asked to administer a coping measurement instrument to a patient. What education would the nurse present to the patient related to this tool? a. "This tool will let us compare your stress to other patients in the hospital." b. "This tool is short because it only measures the negative stressors you are experiencing." c. "You will need to ask your parents about stressors you had as a child to complete this tool." d. "This tool will help assess recent positive and negative events you are experiencing."

ANS: D Coping measurement tools measure recent positive and negative life events as perceived by the individual. There is no objective scale for comparison with other patients because each person reacts differently to stressors. Both negative and positive events are assessed. Childhood stressors are not part of this type of evaluation as they are intended to measure recently occurring events.

An obese female patient who had enjoyed active outdoor activities is stressed because osteoarthritis in her hips now limits her activity. Which action by the nurse will best assist the patient to cope with this situation? a. Have the patient practice frequent relaxation breathing. b. Ask the patient what outdoor activities she misses the most. c. Teach the patient to use imagery for reducing pain and stress. d. Encourage the patient to consider weight loss to improve symptoms.

ANS: D For problems that can be changed or controlled, problem-focused coping strategies, such as encouraging the patient to lose weight, are most helpful. The other strategies also may assist the patient in coping with her problem, but they will not be as helpful as a problem-focused strategy.

A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery d. Relaxation breathing

ANS: D Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult for the nurse to provide massage while assisting with the biopsy. Meditation and guided imagery require more time to practice and learn.

A middle-aged male patient with usually well-controlled hypertension and diabetes visits the clinic. Today he has a blood pressure of 174/94 mm Hg and a blood glucose level of 190 mg/dL. What patient information may indicate that additional intervention by the nurse is needed? a. The patient states that he takes his prescribed antihypertensive medications daily. b. The patient states that both of his parents have high blood pressure and diabetes. c. The patient indicates that he does blood glucose monitoring several times each day. d. The patient reports that he and his wife are disputing custody of their 8-yr-old son.

ANS: D The increase in blood pressure and glucose levels possibly suggests that stress caused by his divorce and custody battle may be adversely affecting his health. The nurse should assess this further and develop an appropriate plan to assist the patient in decreasing his stress. Although he has been very compliant with his treatment plan in the past, the nurse should assess whether the stress in his life is interfering with his management of his health problems. The family history will not necessarily explain why he has had changes in his blood pressure and glucose levels.

Since learning that he will have a trial pass to a new group home tomorrow, Luke's usual behavior has changed. He has started to pace, has become distracted, and is breathing rapidly. He has trouble focusing on anything other than the group home issue and complains that he suddenly feels nauseated. Which initial nursing response is most appropriate for Luke's level of anxiety? a. "You seem anxious. Would you like to talk about how you are feeling?" b. "If you do not calm down, I will have to give you prn medicine to help you." c. "Luke, slow down. Listen to me. You are safe. Take a deep breath, and let's go to a quieter place." d. "We can delay the visit to the group home if that would help you calm down."

Which statement concerning syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered true? A Dissociative disorders such as dissociative identify disorders B Physical disorders, not mental disorders C Culture-bound syndromes that are not dissociative disorders D Myths, or rumors, because they have not been sufficiently studied to be classified as real.

A Gulf War veteran is entering treatment for post-traumatic stress disorder. An important facet of assessment is to a. ascertain how long ago the trauma occurred. b. find out if the client uses acting-out behavior. c. determine use of chemical substances for anxiety relief. d. establish whether the client has chronic hypertension related to high anxiety.

C (.Substance abuse often coexists with post-traumatic stress disorder. It is often the client's way of self-medicating to gain relief of symptoms.)

Which nursing diagnosis would be most useful for clients with anxiety disorders? a. Excess fluid volume b. Disturbed body image c. Ineffective role performance d. Disturbed personal identity

C (Anxiety disorders often interfere with the usual role performance of clients. Consider the client with agoraphobia who cannot go to work, or the client with obsessive-compulsive disorder who devotes time to the ritual rather than to parenting.)

A child who was physically and sexually abused is at great risk for demonstrating which characteristic? a. Depression b. Suicide attempts c. Bullying and abusing others d. Becoming active in a gang

C (Children who have been abused are at risk for abusing others, as well as for developing dysfunctional patterns in close interpersonal relationships. While the other characteristics may occur, none are as characteristic as the correct option.REF: 295)

Dissociative identity disorder is characterized by what event? a. The inability to recall important information b. Sudden, unexpected travel away from home and inability to remember the past c. The existence of two or more subpersonalities, each with its own patterns of thinking d. Recurring feelings of detachment from one's body or mental processes

C (Dissociation is an unconscious defense mechanism that protects the individual against overwhelming anxiety through an emotional separation. However, this separation results in disturbances in memory, consciousness, self-identity, and perception. None of the other options accurately characterizes this form of mental dysfunction.REF: 296-297)

A young adult applying for a position is mildly tense but eager to begin the interview. This can be assessed as showing a. denial. b. compensation. c. normal anxiety. d. selective inattention.

C (Normal anxiety is a healthy life force needed to carry out the tasks of living and striving toward goals. It prompts constructive actions.)

Panic attacks in Latin American individuals often involve a. repetitive involuntary actions. b. blushing. c. fear of dying. d. offensive vebalizations.

C (Panic attacks in Latin Americans and Northern Europeans often involve sensations of choking, smothering, numbness or tingling, as well as fear of dying.)

A person who recently gave up smoking and now talks constantly about how smoking fouls the air, causes cancer, and "burns" money that could be better spent to feed the poor is demonstrating a. projection. b. rationalization. c. reaction formation. d. undoing.

C (Reaction formation keeps unacceptable feelings or behaviors out of awareness by developing the opposite behavior or emotion.)

The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? a. Having the client repeatedly touch "dirty" objects b. Not allowing the client to seek reassurance from staff c. Not allowing the client to wash hands after touching a "dirty" object d. Telling the client that he or she must relax whenever tension mounts

C (Response prevention is a technique by which the client is prevented from engaging in the compulsive ritual. A form of behavior therapy, response prevention is never undertaken without physician approval.)

A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client's level of anxiety as a. mild. b. moderate. c. severe. d. panic.

C (Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart.)

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next? a. beta blocker b. Barbiturate c. Tricyclic antidepressant (TCA) d. sedative

C (TCAs or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. None of the other options would be the next consideration.REF: 304-305)

Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD? (Select all that apply.) A Visiting the scene of the accident over and over B Talking with strangers about the events of the accident C Flashbacks of the accident D Hypervigilance E Irritability F Difficulty concentrating G Mania

C, D, E, G

The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of a. standard antipsychotic medication. b. tricyclic antidepressant medication. c. anticholinergic medication. d. a short-acting benzodiazepine medication.

D (A short-acting benzodiazepine is the only type of medication listed that would lessen the client's symptoms of anxiety within a few minutes. Anticholinergics do not lower anxiety; tricyclic antidepressants have very little antianxiety effect and have a slow onset of action; and a standard antipsychotic medication will lower anxiety but has a slower onset of action and the potential for more side effects.)

The major distinction between fear and anxiety is that fear a. is a universal experience; anxiety is neurotic. b. enables constructive action; anxiety is dysfunctional. c. is a psychological experience; anxiety is a physiological experience. d. is a response to a specific danger; anxiety is a response to an unknown danger.

D (Fear is a response to an objective danger; anxiety is a response to a subjective danger.)

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. Which response should the nurse provide to best address the parent's concerns? a. Children of this age usually have imaginary friends. b. It is nothing to worry about unless the child starts to socially isolate. c. The child needs more of their one-on-one attention. d. The imaginary friend is a coping mechanism the child is using.

D (Often traumatized children feel responsible for what happened to them and are frightened by flashbacks, amnesia, or hallucinations that may be due to trauma. For example, a child may use imaginary friends as a coping mechanism. This option addresses the parents' concern most effectively.REF: 300-301)

Delusionary thinking is a characteristic of a. chronic anxiety. b. acute anxiety. c. severe anxiety. d. panic level anxiety.

D (Panic level anxiety is the most extreme level and results in markedly disturbed thinking.)

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? a. A 13 year old male b. A 10 year old female c. A 7 year old male d. A 4 year old female

D (The developing brain is particularly vulnerable to adverse events because the most rapid brain development occurs in the first five years of life. The right hemisphere is involved in processing social-emotional information, promoting attachment functions, regulating body functions, and in supporting the individual in survival and in coping with stress. Since the right brain develops first and is involved with developing templates for relationships and regulation of emotion and bodily function, early attachment relationships are particularly important for healthy development and life-long health.REF: 303)

A symptom commonly associated with panic attacks is a. obsessions. b. apathy. c. fever. d. fear of impending doom.

D (The feelings of terror present during a panic attack are so severe that normal function is suspended, the perceptual field is severely limited, and misinterpretation of reality may occur.)

Working to help the client view an occurrence in a more positive light is called a. flooding. b. desensitization. c. response prevention. d. cognitive restructuring.

D (The purpose of cognitive restructuring is to change the individual's negative view of an event or a situation to a view that remains consistent with the facts but that is more positive.)

The primary purpose of performing a physical examination before beginning treatment for any anxiety disorder is to a. protect the nurse legally. b. establish the nursing diagnoses of priority. c. obtain information about the client's psychosocial background. d. determine whether the anxiety is primary or secondary in origin.

D (The symptoms of anxiety can be caused by a number of physical disorders or are said to be caused by an underlying physical disorder. The treatment for secondary anxiety is treatment of the underlying cause.)

A variety of medications are used in the treatment of severe anxiety disorders. Which class of medication used to treat anxiety is potentially addictive? a. Selective serotonin reuptake inhibitors (SSRIs) b. β-blockers c. Antihistamines d. Buspirone e. Benzodiazepines

A patient is admitted to the emergency department for treatment of a possible opioid overdose. Rank the nursing activities in the correct order from first activity to last activity. (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Initiate IV access. b. Take a health history. c. Administer naloxone d. Obtain a toxicology screen e. Provide respiratory support with a bag-valve mask.

E, A, C, D, B Maintenance of the airway is the first priority for patients with possible depressant overdose. Opioid antagonists are given before toxicology testing is done because reversal of the opioid will prevent respiratory arrest. However, this will require IV access. The toxicology report will help guide further treatment for possible multiple substance ingestions. The health history will guide care after the initial emergency treatment phase.

A primary health care provider instructed a nurse to give cognitive-behavioral therapy to a patient with social phobia. What intervention is appropriate for the patient during the cognitive-behavior therapy? a. Re-evaluate the patient's situation. b. Support the patient's beliefs. c. Give an opinion on patient's thoughts. d. Calm the patient through isolation from peers.

a. The patients must be given cognitive-behavioral therapy to remove the negative feelings. The nurse should re-evaluate the situation realistically. The nurse should develop a positive insight in the patient by replacing the negative thoughts. The nurse should not support the patient's negative beliefs. It can further disrupt the patient's beliefs. The nurse should not give her own opinion on the patient's thoughts as it may make the patient feel rejected. The nurse should not isolate the patient from peers as it can cause withdrawal and aggression in the patient. The nurse should encourage the patient to mingle with peers. p. 291

What information will the nurse include in medication education for a patient prescribed an antianxiety medication for obsessive-compulsive behavior? SATA a. Caffeine beverages should be avoided. b. Antacid use can affect medication absorption. c. Benzodiazepines have a quick onset of action. d. Medication should be taken on an empty stomach. e. The medication is recommended for long-term use.

a. b. c. Benzodiazepines are used most commonly for treatment of anxiety disorders because they have a quick onset of action; however, because of the potential for dependence, these medications ideally should be used for short periods only until other medications or treatments reduce symptoms. Beverages containing caffeine should be avoided because they decrease the desired effects of the drug. Antacids may delay absorption. Medications should be taken with or shortly after meals to reduce gastrointestinal discomfort. p. 288

What question would assist a nurse in determining whether a patient diagnosed with obsessive-compulsive disorder has achieved treatment outcomes? SATA a. Can the patient meet his or her own self-care needs effectively? b. Is the patient able to maintain satisfying interpersonal relationships? c. Does the patient understand that anxiety is the cause of the ritual behavior? d. Has the patient learned to use newly acquired methods to manage anxiety? e. Have the patient's cognitive abilities improved since beginning treatment?

a. b. c. d. In general, evaluation of outcomes for patients with anxiety and obsessive-compulsive disorders deals with questions such as: Can the patient maintain satisfying interpersonal relations? Does the patient adequately perform self-care activities? Is the patient able to use newly learned behaviors to manage anxiety? Does the patient recognize symptoms as anxiety-related? Cognitive abilities are not related directly to obsessive-compulsive disorders. p. 291

What mental health disorder can be a direct physiological result of hyperthyroidism? a. Anxiety b. Panic attacks c. Generalized anxiety disorder d. Obsessive-compulsive disorder

b. Anxiety can be a direct physiological result of hyperthyroidism. Panic attacks are a key feature of panic disorders. Generalized anxiety disorder is excessive worry, which is out of proportion to the true impact of events or situations. It is often comorbid with major depressive disorder and other anxiety disorders. Obsessive-compulsive disorder is characterized by both obsession and compulsions that may occur due to a genetic disposition or trauma. p. 279

When prescribed lorazepam 1 mg orally, four times a day, for one week, for generalized anxiety disorder, the nurse should a. Tell the patient to expect mild insomnia b. Teach the patient to limit caffeine intake c. Explain the long-term nature of benzodiazepine therapy d. Question the health care provider's prescription because the dose is excessive

b. Caffeine is an antagonist of antianxiety medication. p. 288

After reviewing the following information, which intervention best demonstrates the importance of the research findings? a. Coordinate the patient's diagnostic testing to determine neurotrophin BDNF levels. b. Include an age- and ability-appropriate exercise routine in each patient's daily routine. c. Include an orientation to the various exercise equipment available on the unit as part of the admission process. d. Educate the patients to the connection between neurotrophin brain-derived neurotrophic factor (BDNF) and anxiety.

b. Implications for Nursing Practice identified by the study encouraged nurses to promote a prescription of daily exercise. Including an age ability appropriate exercise into a patient's daily routine best implements the conclusion of this research. Although educating the patients to the connection between neurotrophin BDNF and anxiety, coordinating the patient's diagnostic testing to determine neurotrophin BDNF levels, and including an orientation to the various exercise equipment available on the unit as a part of the admission process are appropriate, these interventions do not directly implement exercise into a patient's daily routine. p. 286

An important question to ask during the assessment of a patient diagnosed with anxiety disorder is a. "How often do you hear voices?" b. "Have you ever considered suicide?" c. "How long has your memory been bad?" d. "Do your thoughts always seem jumbled?"

b. The presence of anxiety may cause an individual to consider suicide as a means of finding comfort and peace. Suicide assessment is appropriate for any patient with higher levels of anxiety. p. 284

The defense mechanisms that can be used only in healthy ways include a. Suppression and humor b. Altruism and sublimation c. Idealization and splitting d. Reaction formation and denial

b. Altruism and sublimation are known as mature defenses. They cannot be used in unhealthy ways. Altruism results in resolving emotional conflicts by meeting the needs of others, and sublimation substitutes socially acceptable activity for unacceptable impulses. p. 272

After a year of diarrhea, a patient has a colonoscopy. As the health care provider explains the findings, the patient rapidly says, "You're talking too fast. I can't understand you. All I can hear is a buzz from the fluorescent lights." The patient is wet with perspiration. Which level of anxiety is evident? a. Mild b. Panic c. Severe d. Moderate

c. Symptoms of severe anxiety evident in this scenario are confusion, diaphoresis (sweating), withdrawal, rapid speech, and a perceptual field that is reduced greatly and distorted. The perceptual field is heightened in mild anxiety. In moderate anxiety, the ability to think clearly is hampered, but learning and problem solving can still take place. In panic, communication is unintelligible or there is an inability to speak. p. 272, Table 15.1

A possible outcome criterion for a patient diagnosed with anxiety disorder is a. Patient reports reduced hallucinations b. Patient reports feelings of tension and fatigue c. Patient demonstrates effective coping strategies d. Patient demonstrates persistent avoidance behaviors

c. The patient demonstrating effective coping strategies is the only desirable outcome. p. 284

A patient is displaying symptomology reflective of a panic attack. To help the patient regain control, the nurse responds, a. "You need to calm yourself." b. "What is it that you would like me to do to help you?" c. "Can you tell me what you were feeling just before your attack?" d. "I will get you some medication to help calm you."

c. A response that helps the patient identify the precipitant stressor is most therapeutic. p. 276

When discussing the symptoms of post-traumatic stress disorder (PTSD), the nurse should make which statement? A "The symptoms can occur almost immediately or can take years to manifest." B "PTSD causes agitation and hypervigilance but rarely chronic depression." C "When experiencing a flashback, the client generally experiences a slowing of responses." D "PTSD is an emotional response that does not cause significant changes in brain chemistry."

A nurse is caring for a client who has a new prescription for phenelzine for the treatment of depression. Which of the following indicates that the client has developed an adverse effect of this medication? a. orthostatic hypotension b. hearing loss c. GI bleeding d. weight loss

A Orthostatic hypotension is an adverse effect of MAOIs

The symptoms of an adjustment disorder can include characteristics? (Select all that apply.) A Guilt B Social withdrawal C Overachieving D Anger E Depression

A, B, D, E

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.

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.

A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly." d. "The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other."

ANS: A Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships.

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.

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.

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.

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

ANS: A The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

ANS: A The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

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.

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.

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.

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.

A nurse introduces the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.

ANS: B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. "Working with" is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

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.

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.

The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"

ANS: B Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication

ANS: B Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications

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.

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.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

ANS: B Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world.

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-revelation in patient interactions. d. consistently interpret the patient's behaviors.

ANS: B Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.

ANS: B Ongoing monitoring is recommended for patients with MCI. MCI does not interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for MCI.

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.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.

ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past

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.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

ANS: B The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

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.

Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.

ANS: B, C LPN/LVN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)-level education and scope of practice.

The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.

ANS: B, C, E The stress of being a caregiver can be managed with a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a. "Accepting gifts violates the policies and procedures of the facility." b. "I'm glad you feel so much better now. Thank you for the beautiful necklace." c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

ANS: C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted.

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.

When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.

ANS: C Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. self-responsibility and autonomy. b. a greater sense of independence. c. rapport and trust with the nurse. d. resolved transference.

ANS: C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination

ANS: C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, 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.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient's ability to recognize a common object such as a pen.

ANS: C In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer's disease, but are not part of the Mini-Cog exam

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.

The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.

ANS: C Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.

ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

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

A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.

ANS: C Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions can be frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering

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.

*After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference?* a. The patient's reactions toward the nurse seem realistic and appropriate. b. The patient states, "Talking to you feels like talking to my parents." c. The nurse feels unusually happy when the patient's mood begins to lift. d. The nurse develops a trusting relationship with the patient.

ANS: C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable.

*Termination of a therapeutic nurse-patient relationship has been successful when the nurse:* a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

ANS: C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact.

A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.

ANS: C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD

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.

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination

ANS: C This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

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.

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast

ANS: D A new cough after a meal in a patient with dementia suggests possible aspiration and the patient should be assessed immediately. The other patients also require assessment and intervention, but not as urgently as a patient with possible aspiration or pneumonia

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.

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.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

ANS: D The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints are not recommended because they can increase the patient's agitation and disorientation

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.

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about problems." c. "I don't know how it will help to talk to you about my problems." d. "I want to find a way to deal with my anger without becoming violent."

ANS: D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase.

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.

A nurse is providing teaching to a client who has a new prescription for amitryptyline for treatment of depression. Which of the following should the nurse include in the teaching? (Select all that apply.) a. expect therapeutic effects in 24-48 hrs b. discontinue the medication after a week of improved mood c. change positions slowly to minimize dizziness d. decrease dietary fiber intake to control diarrhea e. chew sugarless gum to prevent dry mouth

C, E

As a part of group therapy, a patient with anxiety disorder was asked to deliver a speech to the group. However, the patient was unable to perform the given task and started avoiding the nurse. How should the nurse relieve the anxiety of the patient? SATA a. The nurse leaves the patient alone in a room. b. The nurse talks slowly and calmly with the patient. c. The nurse asks the patient to write a list of his or her strengths. d. The nurse encourages the patient to discuss the reason for fear. e. The nurse gives strict instructions to the patient to complete the given task.

b, c, d The symptoms of generalized anxiety disorder include inability to perform a given task and avoiding interacting with others. The nurse should make the patient feel safe by talking slowly and calmly. The nurse can increase the self-esteem of the patient by giving the task to write and asses the strengths of himself or herself. The nurse encourages the patient to discuss the reason for fear. It helps the nurse to identify possible stressors and to eliminate them from the patient's surroundings. The nurse should avoid giving strict instructions to the patient as it may hinder nurse-patient communication. Brief instructions enable the patient to respond in a healthy manner. The nurse should not leave the patient alone but stay with the patient to convey acceptance. p. 278

What is included in the nursing plan of care for a patient diagnosed with anxiety who is exhibiting severe hyperactivity? a. Place the patient in seclusion. b. Attend to the patient's physical needs. c. Help the patient identify the source of anxiety. d. Communicate using simple, loud, clear statements.

b. The nursing care plan for a patient diagnosed with anxiety who is exhibiting severe hyperactivity is to attend to the patient's physical needs. Severe hyperactivity is characteristic of a panic level of anxiety and attending to physical needs such as elimination, fluids, and nutrition are important. Seclusion should be initiated after all other interventions have been tried and are unsuccessful. Helping a patient identify the source of anxiety is more effective for a patient experiencing mild to moderate anxiety. When the nurse is communicating with a patient experiencing severe anxiety, a low-pitched voice should be used. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect. p. 286

Which category of medication used to treat anxiety has a potential for dependence? a. Tricyclics b. Benzodiazepines c. Selective serotonin reuptake inhibitors d. Selective serotonin norepinephrine reuptake inhibitors

b. Benzodiazepines commonly are prescribed for anxiety because they have a quick onset of action; however, because of the potential for dependence, these medications ideally should be used for short periods. Benzodiazepines are not recommended for patients with a known substance abuse history. Tricyclics, selective serotonin reuptake inhibitors, and selective serotonin norepinephrine reuptake inhibitors do not create dependency. p. 288

The nurse is providing teaching to a preoperative patient just before surgery. The patient is becoming more and more anxious as the information is presented. Soon the patient begins to report dizziness and heart pounding. The nurse observes obvious trembling and that the patient appears confused. What is the nurse's immediate intervention? a. Reinforcing the preoperative teaching by restating it slowly b. Ceasing any further attempt at preoperative teaching at this time c. Having the patient read the teaching materials instead of listening to them d. Having a familiar family member read the preoperative materials to the patient

b. Patients experiencing severe anxiety, as the symptoms suggest, are unable to learn or solve problems. Restating the preoperative teaching slowly, having the patient read the teaching materials instead of listening to them, and having a familiar family member read the preoperative materials to the patient would not be effective because the nurse is still attempting to teach someone who has a severe level of anxiety. p. 272

A patient counts everything; for example, the patient counts the number of steps to the bathroom, rings of the telephone, and cups in the pantry. How should the nurse document this finding? a. Phobia b. Obsession c. Compulsion d. Trichotillomania

c. Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety or prevent an imagined calamity. Performing the compulsive act temporarily reduces anxiety, but because the relief is only temporary, the compulsive act must be repeated again and again. A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance, or actual avoidance, of the object, activity, or situation. Obsessions are thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the mind even though the individual attempts to do so. Obsessions often seem senseless to the individual who experiences them (ego-dystonic), and their presence causes severe anxiety. Trichotillomania refers to hair pulling disorder. p. 278

After three weeks of hemoptysis (coughing blood), a person finally seeks treatment. A chest x-ray film is taken and the person waits for the results. When the health care provider explains the report, the person complains, "I can't understand what you're saying. You're talking so fast. All I hear is a loud clicking on my watch." The patient is wet with perspiration. Which level of anxiety is evident? a. Mild b. Panic c. Severe d. Moderate

c. Indicators of severe anxiety include cognitive, narrowed perceptual field, selective attention, distortion of time/events, detachment, physical reactions such as diaphoresis, tense muscles, and decreased hearing. Mild anxiety is demonstrated by normal vital signs, minimal muscle tension, broad perceptual field, and awareness of environmental and internal stimuli. There are also feelings of relative comfort, a relaxed appearance, and automatic performance. Moderate anxiety is demonstrated by slightly elevated vital signs; moderate muscle tension; alert, narrow, or focused attention; and inability to problem solve, learn, and be attentive. There is also a feeling of readiness, energy, ability to learn, and interest in the situation. Panic is characterized by a distinct inability to respond to any stimuli other than those occurring internally and a sense of being out of control, physically and emotionally. p. 272

The nurse anticipates that the nursing history of a patient diagnosed with obsessive compulsive disorder (OCD) will reveal a. A phobia as well b. An eating disorder c. A sibling with the disorder d. A history of childhood trauma

c. Research shows that first-degree biological relatives of those with OCD have a higher frequency of the disorder than exists in the general population. p. 281

A nurse is providing discharge teaching to a client who has a new prescription for fluoxetine for PTSD. Which of the following statements should the nurse include in the teaching? a. "You may have a decreased desire for intimacy while taking this medication" b. "You should take this medication at bedtime to help promote sleep" c. "You will have fewer urinary adverse effects if you urinate just before taking this medication" d. "You will need to wear sunglasses when outdoors due to the light sensitivity caused by this medication"

Which statement about structural dissociation of the personality is true? A An organic basis exists for this type of disorder. B Nurses perceive clients with this disorder as easy to care for. C No known link exists between this disorder and early childhood loss or trauma. D This disorder results in a split in the personality causing a lack of integration.

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

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. "You must have been very upset when you tried to hurt yourself." b. "It makes me sad to see you going through such a difficult experience." c. "If you tell me what is troubling you, I can help you solve your problems." d. "Suicide is a drastic solution to a problem that may not be such a serious matter."

ANS: A Empathy permits the nurse to see an event from the patient's perspective, understand the patient's feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse's feelings rather than the patient's), belittling, and sympathetic.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Keep blinds open during the daytime hours. b. Provide hourly orientation to time and place. c. Have the patient take a brief mid-morning nap. d. Move the patient to a quieter room late in the afternoon.

ANS: A A likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia

*A patient says, "Please don't share information about me with the other people." How should the nurse respond?* a. "I will not share information with your family or friends without your permission, but I share information about you with other staff." b. "A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know." c. "It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

ANS: A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered.

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.

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next? A Beta blocker B Barbiturate C Tricyclic antidepressant (TCA) D Sedative

A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"

ANS: D This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should: a. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, "I am not available to talk with you at the present time." c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, "This session is 5 more minutes; then I will talk with you."

ANS: D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

A nurse is caring for a client who has been taking sertraline for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome? a. bruising b. fever c. tinnitus d. rash

What symptom can the nurse expect a client diagnosed with depersonalization disorder to manifest? A Aimless wandering with confusion and disorientation B A feeling of detachment from one's body or mental processes C Existence of two or more personalities that take control of behavior D Worry about having a serious disease based on symptom misinterpretation

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? A Overeating B Hypervigilance C A drive to be perfect D Passivity

A 4 years old is referred to the outpatient mental health clinic after being in a severe car accident during which the child mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, "It's my fault because I'm bad." What trauma induced disorder does this data support? A Adjustment disorder B Dissociative identity disorder C Posttraumatic stress disorder (PTSD) D Acute stress disorder (ASD)

A child who was physically and sexually abused is at great risk for demonstrating which characteristic? A Depression B Suicide attempts C Bullying and abusing others D Becoming active in a gang

What characteristics are associated with moderate anxiety? SATA a. The person engages in selective inattention. b. Learning and problem solving are no longer possible. c. People routinely describe a feeling of "impending doom." d. Gastric discomfort and headaches sometimes are reported. e. The sympathetic nervous system begins to control vital signs.

a, d, e. The person experiencing moderate anxiety sees, hears, and grasps less information and may demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they are pointed out. Sympathetic nervous system symptoms begin to kick in. The individual may experience tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic symptoms (e.g., gastric discomfort, headache, urinary urgency). The ability to think clearly is hampered, but learning and problem solving can still take place, although not at an optimal level. A feeling of impending doom is associated with severe anxiety. pp. 271, 272

A nurse is caring for a patient with claustrophobia. The primary health care provider instructed the nurse to leave the patient in a closed room for 30 minutes daily. Which behavioral therapy was the nurse instructed to implement? a. Flooding b. Modeling c. Thought-stopping d. Response prevention

a. In flooding, the patient is exposed to the fear stimuli repeatedly. With prolonged exposure to the fear, the patient learns to overcome and survive the fear. In modeling, the staff and nurse act as role models and demonstrate appropriate behavior to the fear stimuli. In response prevention, the nurse doesn't allow the patient to perform the ritual response; it can be used in obsessive-compulsive patients. Thought-stopping is used to interrupt the negative thoughts in the patient. The nurse recommends that patients snap a rubber band on their wrist to cause a distraction from negative thoughts. p. 290

Which therapeutic intervention can the nurse implement personally to help a patient diagnosed with a mild anxiety disorder regain control? a. Flooding b. Modeling c. Thought stopping d. Systematic desensitization

b. Modeling calm behavior in the face of anxiety or unafraid behavior in the presence of a feared stimulus are interventions that can be used independently. Flooding, thought stopping, and systematic desensitization require agreement of the treatment team. p. 285

A patient is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the patient reports a. Repeatedly verbalizing prayers helps the patient feel relaxed b. That eating in public makes the patient extremely uncomfortable c. That the symptoms started right after the patient was robbed at gunpoint d. Being so worried the patient hasn't been able to work for the last 12 months

d. GAD is characterized by symptomology that lasts six months or longer. p. 277

Which nursing intervention would be helpful when caring for a patient diagnosed with an anxiety disorder? a. Express mild amusement over symptoms. b. Arrange for patient to spend time away from others. c. Advise patient to minimize exercise to conserve endorphins. d. Reinforce use of positive self-talk to change negative assumptions.

d. This technique is a variant of cognitive restructuring. "I can't do that" is changed to "I can do it if I try." p. 276

A family member of a recovering alcoholic states, "All my mother talks about now is how bad drinking is when she drank for years." What is the nurse's understanding of the statement? a. The recovering alcoholic is demonstrating adaptive sublimation. b. The recovering alcoholic is demonstrating maladaptive displacement. c. The recovering alcoholic is demonstrating adaptive reaction formation. d. The recovering alcoholic is demonstrating maladaptive intellectualization.

c. The nurse understands that the recovering alcoholic is demonstrating adaptive reaction formation, when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion. An example is a recovering alcoholic constantly talking about the harm of drinking. Sublimation is an unconscious process of substituting a mature and socially acceptable activity for immature and unacceptable impulses. Displacement is the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question. p. 274

TEST ONE: Cognition and Coping review questions

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Section 3.2 HW

MGMT 478 Ch.10

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PU-CH43

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Peds Chapter 46

Construction Drawings Lesson 2: Scaling and Dimensions

BLAW EXAM 2

final ch 38

Chapter 15 Terms and Questions

Cognitive Exam 3 (Final)

chapter 6

Sports Psychology EXAM 1

Silvestri NCLEX test 5

Las Preguntas Finales

Boot Options

*****TEST ONE: Cognition and Coping review questions*****

Conjuntos de estudio relacionados

Life Insurance: Individual Life Insurance Contract - Provisions and Options

CRIM JUSTICE CH 5 & 6

Section 3.2 HW

MGMT 478 Ch.10

Math

PU-CH43

Management 428 Chapter 1

Micro Exam 3

Chapter 1 economics

Peds Chapter 46

Construction Drawings Lesson 2: Scaling and Dimensions

BLAW EXAM 2

final ch 38

Chapter 15 Terms and Questions

Cognitive Exam 3 (Final)

chapter 6

Sports Psychology EXAM 1

Silvestri NCLEX test 5

Las Preguntas Finales

Boot Options

TEST ONE: Cognition and Coping review questions