Week 6: Promoting Self-Esteem CHP 14, Children and Adolescents CHP 32, Issues Related to Human Sexuality and Gender Dysphoria CHP 42, Eating Disorders CHP 30, & Intervention with Families CHP 10

A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this clients diagnosis? A. The client will name own body parts as separate from others by day 5. B. The client will establish a means of communicating personal needs by discharge. C. The client will initiate social interactions with caregivers by day 4. D. The client will not harm self or others by discharge.

ANS: A An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

A nursing diagnosis of ineffective coping R/T feelings of loneliness AEB bingeing then purging when alone, is assigned to a client diagnosed with bulimia nervosa. Which is an appropriate outcome related to this nursing diagnosis? A. The client will identify two alternative methods of dealing with isolation by day 3. B. The client will appropriately express angry feelings about lack of control by week 2. C. The client will verbalize two positive self attributes by day 3. D. The client will list five ways that the body reacts to bingeing and purging.

ANS: A The ability to identify alternative methods of dealing with isolation will provide the client with effective coping strategies to use instead of bingeing and purging.

An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this clients situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: A The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.

A 40-year-old female client has never experienced an intimate relationship. A nursing student tells an instructor that this client remains in Eriksons developmental stage of intimacy versus isolation. What is the instructors most appropriate reply? A. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. B. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age. C. Eriksons stages of development are assessed by task achievement, not chronological age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age. D. Eriksons stages of development are assessed by chronological age, not task achievement. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age.

ANS: A Eriksons stages of development are assessed by chronological age, not task achievement. This client is in Eriksons stage of generativity versus stagnation because she is 40 years old. The student has failed to recognize that even though the client did not successfully achieve the intimacy task of the intimacy versus isolation stage, the client must now be assessed at the age-appropriate developmental stage of generativity versus stagnation.

A client has continual problematic relationships and rejects others before possibly being rejected. The client states, I am afraid of failing in my job responsibilities. Which correctly written nursing diagnosis should be prioritized for this client? A. Poor self-esteem R/T negative self-image AEB fear of failure B. Altered thought processes R/T anxiety AEB delusions C. Role confusion R/T rejection and poor job productivity D. High risk for violence: self-directed R/T rejection of others

ANS: A Individuals with low self-esteem perceive themselves to be incompetent, unlovable, insecure, and unworthy. A correctly written actual nursing diagnosis must have a related to (R/T) and an evidenced by (AEB) statement. A risk for nursing diagnosis does not contain an AEB statement because the problem has not yet occurred.

A client reports, during his visit to the mental health clinic, that he is distressed by repetitive sexual fantasies that involve humiliating his sexual partner. This would most appropriately be assessed as what type of disorder? A. Paraphilic disorder B. Obsessive-compulsive disorder C. Erectile disorder D. Hypoactive sexual desire disorder

ANS: A Paraphilic disorders include repetitive or preferred sexual fantasies or behaviors that involve nonhuman objects, suffering or humiliation to oneself or ones partner, or nonconsenting persons. Diagnostic criteria include a duration of symptoms for at least 6 months and clinically significant distress caused by the symptoms.

3. A nurse is running a group on self-esteem. A client asks, Where does self-esteem come from? Which is the most appropriate nursing reply? A. Many factors, over the life span, influence development and maintenance of self-esteem. B. Self-esteem is determined by factors outside of an individuals control. C. Self-esteem is established in childhood and remains relatively fixed throughout life. D. Genetics are the single largest contributor to an individuals self-esteem.

ANS: A Self-esteem refers to the degree of regard or respect that individuals have for themselves and is a measure of worth that they place on their abilities and judgments. Many factors influence the development of self-esteem over a persons life span.

Which is an appropriate initial nursing intervention for a client with chronic low self-esteem? A. Assessing the content of negative self-talk B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques

ANS: A Self-negating verbalizations and internal self-talk undermine self-esteem. Assessing and then intervening to limit or eliminate these negative communications will help improve self-esteem.

A clinic nurse is caring for a 40-year-old client who lives with his parents. The clients mother continues to do the clients laundry and provides spending money. Based on this situation, which family dynamic does the nurse recognize? A. Taking over B. Communicating indirectly C. Belittling feelings D. Making assumptions

ANS: A Taking over occurs when a family member fails to allow another member to develop a sense of responsibility and self-worth. By doing the clients laundry and managing finances, the mother is fostering the clients dependence.

An instructor is teaching about differentiated parent and adult child relationships. Students are instructed to give an example of a well-differentiated parent and adult child relationship. Which student example meets the instructor requirement? A. An adult child considers, but is not governed by, the advice of his or her parents. B. An adult child appears to listen, but ignores, the advice of his or her parents. C. An adult child respects and is governed by the wishes of his or her parents. D. An adult child never requests advice or feedback from his or her parents.

ANS: A The correct student example of a well-differentiated parent and adult child relationship is when an adult child considers, but is not governed by, the advice of his or her parent. The adult child should be differentiated enough not to be threatened by parental advice and should be able to consider the parental advice without feeling the advice must be followed.

A nurse observes dental deterioration when assessing a client diagnosed with bulimia nervosa. What explains this assessment finding? A. The emesis produced during purging is acidic and corrodes the tooth enamel. B. Purging causes the depletion of dietary calcium. C. Food is rapidly ingested without proper mastication. D. Poor dental and oral hygiene leads to dental caries.

ANS: A The nurse recognizes that dental deterioration has resulted from the acidic emesis produced during purging that corrodes the tooth enamel. Excessive vomiting may also lead to dehydration and electrolyte imbalance.

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy

ANS: A The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the clients symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.

In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client? A. Self-assess personal attitudes toward homosexuality B. Review clients possible childhood sexual abuse history C. Encourage discussion of aversion to heterosexual relationships D. Explore clients family history of homosexuality

ANS: A The nurse should initially self-assess personal attitudes toward bisexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourettes disorder? A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications

ANS: A The nurse should recognize that antipsychotic medications are effective in the treatment of Tourettes disorder. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%.

A nursing instructor is teaching students about the differences between the symptoms of anorexia nervosa and the symptoms of bulimia nervosa. Which student statement indicates that learning has occurred? A. Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. B. Clients diagnosed with bulimia nervosa experience amenorrhea, whereas clients diagnosed with anorexia nervosa do not. C. Clients diagnosed with bulimia nervosa experience hypotension, edema, and lanugo, whereas clients diagnosed with anorexia nervosa do not. D. Clients diagnosed with anorexia nervosa have eroded tooth enamel, whereas clients diagnosed with bulimia nervosa do not.

ANS: A The nursing student statement that clients diagnosed with anorexia nervosa experience nutritional deficits, whereas clients diagnosed with bulimia nervosa do not, indicates that learning has occurred. Anorexia is characterized by low caloric and nutritional intake. Bulimia is characterized by episodic, rapid indigestion of large quantities of food, followed by purging.

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: A The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD.

A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this childs behavior. Which student response indicates an appropriate evaluation of the situation? A. This childs behavior must be evaluated according to developmental norms. B. This child has symptoms of attention deficit hyperactivity disorder. C. This child has symptoms of the early stages of autistic disorder. D. This childs behavior indicates possible symptoms of oppositional defiant disorder.

ANS: A The students evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

In defiance of parental wishes, a Japanese teenager succumbs to peer pressure and gets a tattoo. According to Bowens family systems theory, how should the community health nurse interpret the teenagers action? A. The teenager is attempting to differentiate self. B. The teenager is triangulating self. C. The teenager is cutting self off emotionally. D. The teenager is exhibiting antisocial traits.

ANS: A The teenager is taking on some of the cultural values of peers and is beginning to develop a unique identity. This process is called differentiation and is a normal task of adolescence.

A couple is in counseling related to their dysfunctional relationship. Their daughter has recently made a suicide gesture. The nurse should recognize that this might be an example of which family system concept? A. Triangulation B. Pseudohostility C. Double-bind communication D. Pseudomutuality

ANS: A Triangulation occurs when a relationship between two people is dysfunctional. A third person is brought into the relationship to help stabilize it. The couple is triangulating with their daughter. The threatened daughter draws attention from her parents interpersonal conflicts by her own dysfunctional behavior.

A nurse should identify topiramate (Topamax) as the drug of choice for which of the following conditions? Select all that apply. A. Binge eating with obesity B. Bingeing and purging with a diagnosis of bulimia nervosa C. Weight loss with a diagnosis of anorexia nervosa D. Amenorrhea with a diagnosis of anorexia nervosa E. Emaciation with a diagnosis of bulimia nervosa

ANS: A, B The nurse should identify that topiramate (Topamax) is the drug of choice when treating binge eating with obesity and treating bingeing and purging with a diagnosis of bulimia nervosa. Topiramate (Topamax) is a novel anticonvulsant used in the long-term treatment of binge-eating disorder with obesity. The use of Topamax results in a significant decline in mean weekly binge frequency and significant reduction in body weight. With the use of this medication, episodes of bingeing and purging were decreased in clients diagnosed with bulimia nervosa.

A 47-year-old mother of two has recently undergone a radical mastectomy. She refuses to see anyone and remains isolated and withdrawn. Which of the following may be relevant nursing diagnoses for this client? Select all that apply. A. Disturbed body image B. Situational low self-esteem C. Ineffective coping D. Altered thought processes E. Altered sensory perception

ANS: A, B, C The mastectomy is likely to disturb the clients body image. She is ineffectively coping by withdrawing. She may be experiencing negative feelings about herself related to her altered body image, which would result in low self-esteem. None of the symptoms presented indicate a problem with either altered thought or altered sensory perception.

Which of the following risk factors noted during a family history assessment should a nurse associate with the potential development of intellectual disability? Select all that apply. A. A family history of Tay-Sachs disease B. Childhood meningococcal infection C. Deprivation of nurturance and social contact D. History of maternal multiple motor and verbal tics E. A diagnosis of maternal major depressive disorder

ANS: A, B, C The nurse should associate a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to intellectual disability. Major predisposing factors of intellectual disability include: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, environmental influences, and other mental disorders.

A nurse is caring for a client who has recently undergone a radical prostatectomy. Which of the following should the nurse recognize as objective symptoms of low self-esteem? Select all that apply. A. Withdrawal from activities B. A decrease in self-care behaviors C. Poor eye contact D. Reports of pain E. Poor posture

ANS: A, B, C, E Withdrawal from activities, a decrease in self-care behaviors, eye contact, and poor posture are all common objective manifestations of low self-esteem. A report of pain should be evaluated as a physical issue before being attributed solely to low self esteem.

Which of the following characteristics should a nurse identify as normal in the development of human sexuality for an 11-year-old child? Select all that apply. A. The child experiments with masturbation. B. The child may experience homosexual play. C. The child shows little interest in the opposite sex. D. The child shows little concern about physical attractiveness. E. The child is unlikely to want to undress in front of others.

ANS: A, B, E The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11- year-old child. Interest in the opposite sex usually increases during this age, and children often become self- conscious about their bodies.

Which of the following interventions should a nurse anticipate implementing when planning care for children diagnosed with attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. Behavior modification B. Antianxiety medications C. Competitive group sports D. Group therapy E. Family therapy

ANS: A, D, E The nurse should anticipate that behavior modification, group therapy, and family therapy may be implemented in the management of ADHD in children. These interventions are often used in conjunction with psychopharmacology to reduce impulsive and hyperactive behaviors and to increase attention span.

A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

ANS: B A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.

Which nursing intervention is appropriate when caring for clients diagnosed with either anorexia nervosa or bulimia nervosa? A. Provide privacy during meals. B. Remain with the client for at least 1 hour after the meal. C. Encourage the client to keep a journal to document types of food consumed. D. Restrict client privileges when provided food is not completely consumed.

ANS: B A nurse should remain with clients diagnosed with either anorexia nervosa or bulimia nervosa for at least 1 hour after meals. This allows the nurse to monitor for food discarding (anorexia nervosa) and/or self-induced vomiting (bulimia nervosa).

A client who is 5 foot 6 inches tall and weighs 98 pounds is admitted with a medical diagnosis of anorexia nervosa. Which nursing diagnosis would take priority at this time? A. Ineffective coping R/T food obsession B. Altered nutrition: less than body requirements R/T inadequate food intake C. Risk for injury R/T suicidal tendencies D. Altered body image R/T perceived obesity

ANS: B Based on Maslows hierarchy, the priority nursing diagnosis for this client must address physical needs prior to emotional considerations. This client must be immediately physically stabilized due to the life-threatening nature of his or her nutritional status.

A nurse working with a client diagnosed with bulimia nervosa asks the client to recall a time in life when food could be consumed without purging. Which is the purpose of this nursing intervention? A. To gain additional information about the progression of the disease process B. To emphasize that the client is capable of consuming food without purging C. To incorporate specific foods into the meal plan to reflect pleasant memories D. To assist the client to become more compliant with the treatment plan

ANS: B By asking the client to recall a time in life when food could be consumed without purging, the nurse is assessing previously successful coping strategies. This information can be used by the client to modify maladaptive behaviors in the present and future.

A nursing instructor is teaching about the importance of healthy family-member expectations for newly blended families. Which student statement indicates a need for further instruction? A. Healthy family-member expectations should be flexible. B. Healthy family-member expectations should be conforming. C. Healthy family-member expectations should be individual. D. Healthy family-member expectations should be realistic.

ANS: B Conforming is a behavior that interferes with adaptive functioning in terms of family member expectations. This student statement indicates a need for further instruction. Realism, flexibility, and individuality are all characteristics of healthy family-member expectations.

A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the clients self-esteem? A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment

ANS: B Creating the artwork provides expression of feelings and a sense of competence and pride. This will most likely have a positive effect on the clients self-esteem.

During family counseling, a husband tells his wife to spend more time with the family, and she responds by stating, Okay, Ill turn in my resignation tomorrow. The husband replies, I knew it! Youve always been a quitter! How should the nurse interpret the husbands statement? A. The husband is expressing an emotional cutoff. B. The husband is expressing double-bind communication. C. The husband is expressing indirect messages. D. The husband is expressing avoidance behaviors.

ANS: B Double-bind communication sets up no-win situations. The husband has created a situation in which no matter what the wife does, she is wrong.

A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? A. Ritalins sedation side effect assists children by decreasing their energy level. B. How Ritalin works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD. C. Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse. D. Ritalin decreases hyperactivity by increasing serotonin levels.

ANS: B It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD.

On the basis of Eriksons theory, how should a nurse encourage a 40-year-old client to improve his or her self-esteem? A. Encourage the client to review life goals and accomplishments. B. Encourage the client to volunteer at a school, reading to underprivileged children. C. Encourage the client to form lasting intimate relationships. D. Encourage the client to seek recognition for task achievement.

ANS: B Making meaningful contributions to others is a way to meet the developmental task of the generativity versus stagnation (30 to 65 years) stage of Eriksons developmental theory. This action would promote a 40-year-old clients self-esteem.

A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client? A. Risk for situational low self-esteem AEB inability to achieve an erection B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities D. Disturbed body image R/T penile flaccidity AEB client statements

ANS: B On the basis of the clients symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the clients mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.

Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability? A. Meeting all of the clients self-care needs to avoid injury B. Providing simple directions and praising clients independent self-care efforts C. Avoiding interference with the clients self-care efforts in order to promote autonomy D. Encouraging family to meet the clients self-care needs to promote bonding

ANS: B Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate intellectual disability. Individuals with moderate intellectual disability can perform some activities independently and may be capable of academic skill to a second-grade level.

A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of intellectual disability? A. Risk for injury R/T self-mutilation B. Altered social interaction R/T nonadherence to social convention C. Altered verbal communication R/T delusional thinking D. Social isolation R/T severely decreased gross motor skills

ANS: B The appropriate nursing diagnosis associated with this degree of intellectual disability is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual disability and may also experience some limitations in speech communications.

A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, Im such a terrible mother. What did I do to cause this? Which nursing reply is most appropriate? A. Researchers really dont know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored. B. Poor parenting doesnt cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control. C. Research has shown that the mother appears to play a greater role in the development of this disorder than the father. D. Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?

ANS: B The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys.

A 52-year-old client states, My husband is upset because I dont enjoy sex as much as I used to. Which priority client data should a nurse initially collect? A. History of hysterectomy B. Date of last menstrual cycle C. Use of birth control methods D. History of thought disorder

ANS: B The nurse should assess the clients last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms, including a decrease in biological drives and sexual activity.

The family of a client diagnosed with anorexia nervosa becomes defensive when the treatment team calls for a family meeting. Which is the appropriate nursing reply? A. Tell me why this family meeting is causing you to be defensive. All clients are required to participate in two family sessions. B. Family intervention and support are important in your childs recovery. C. Family dynamics are not linked to eating disorders. The meeting is to provide your child with family support. D. Clients diagnosed with anorexia nervosa are part of the family system, and any alteration in family processes needs to be addressed.

ANS: B The nurse should educate the family on the importance of family dynamics, involvement, and support in the treatment of anorexia nervosa. Families engaging in conflict avoidance and struggling with issues of power and control may contribute to the development of this disorder or impede the progress of recovery.

Which finding would be most likely in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The childs mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The childs mother and father have an inconsistent parenting style.

ANS: B The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

A nurse is counseling a client diagnosed with gender dysphoria. Which characteristic would differentiate this disorder from transvestic disorder? A. Clients diagnosed with transvestic disorder are dissatisfied with their gender, whereas clients diagnosed with gender dysphoria are not. B. Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not. C. Clients diagnosed with gender dysphoria never engage in cross-dressing, whereas clients diagnosed with transvestic disorder do. D. Clients diagnosed with transvestic disorder never engage in cross-dressing, whereas clients diagnosed with gender dysphoria do.

ANS: B The nurse should identify that clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not. Both clients diagnosed with gender dysphoria and transvestic disorder may participate in cross-dressing.

A nurse is assessing a client diagnosed with pedophilic disorder. What would differentiate this sexual disorder from a sexual dysfunction? A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: B The nurse should identify that pedophilic disorder is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilic disorder involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.

A child has been recently diagnosed with mild intellectual disability (ID). What information about this diagnosis should the nurse include when teaching the childs mother? A. Children with mild ID need constant supervision. B. Children with mild ID develop academic skills up to a sixth-grade level. C. Children with mild ID appear different from their peers. D. Children with mild ID have significant sensory-motor impairment.

ANS: B The nurse should inform the childs mother that children with mild ID develop academic skills up to a sixth- grade level. Individuals with mild ID are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

ANS: B The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

Which nursing intervention should be prioritized when caring for a child diagnosed with intellectual disability? A. Encourage the parents to always prioritize the needs of the child. B. Modify the childs environment to promote independence and encourage impulse control. C. Delay extensive diagnostic studies until the child is developmentally mature. D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

ANS: B The nurse should prioritize modifying the childs environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors.

A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this clients plan of care? A. Encourage and reward peer contact. B. Provide consistent caregivers. C. Provide a variety of safe daily activities. D. Maintain close physical contact throughout the day.

ANS: B The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autism spectrum disorder. Children diagnosed with autism spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

ANS: B The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with a disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

After hearing parents discuss divorce, a 5-year-old develops behavioral problems. Upon dealing with the childs behavioral issues, the marital relationship conflict decreases. The pediatric clinic nurse should recognize that this is an example of which family system concept? A. Differentiation of self B. Triangulation C. Fusion D. Emotional cutoff

ANS: B Triangulation occurs when a relationship between two people is dysfunctional so a third person is brought into the relationship to help stabilize it. The son and his behavioral problems redirect the focus from the couples marital problems.

A nursing instructor is teaching about the various categories of paraphilic disorders. Which of the following categories are correctly matched with expected behaviors? Select all that apply. A. Exhibitionistic disorder: Mary models lingerie for a company that specializes in home parties. B. Voyeuristic disorder: John is arrested for peering in a neighbors bathroom window. C. Frotteuristic disorder: Peter enjoys subway rush-hour female contact that results in arousal. D. Pedophilic disorder: George can experience an orgasm by holding and feeling shoes. E. Fetishistic disorder: Henry masturbates into his wifes silk panties.

ANS: B, C, E Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show ones genitals to unsuspecting strangers.

The nurse should recognize which of the following findings contribute to a clients development of attention deficit-hyperactivity disorder (ADHD)? Select all that apply. A. The clients father was a smoker. B. The client was born 7 weeks premature. C. The client is lactose intolerant. D. The client has a sibling diagnosed with ADHD. E. The client has been diagnosed with dyslexia.

ANS: B, D The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences such as lead exposure and diet can be linked with the development of ADHD.

A nurse is working in a nursing home. How best can this nurse foster self-esteem in the residents of this facility? A. Allowing them to remain in their rooms as much as they desire to maintain privacy B. Administering anti-anxiety medications as ordered C. Providing a sense of mastery over their environment by giving choices when appropriate D. Teaching assertiveness skills and self-esteem principles

ANS: C A sense of having some power and control over ones life enhances self-esteem.

A child diagnosed with attention deficit-hyperactivity disorder (ADHD) is having difficulty completing homework assignments. What information should the nurse include when teaching the parents about task performance improvement? A. The parents should isolate the child when completing homework to improve focus. B. The parents should withhold privileges if homework is not completed within a 2-hour period. C. The parents should divide the homework task into smaller steps and provide an activity break. D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework.

ANS: C By dividing the homework task into smaller steps, the child can remain more focused within a limited about of time. Physical activity can release pent-up energy that would distract from task completion.

A nurse is working with a client diagnosed with pedophilic disorder. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? A. The client will verbalize an understanding of the importance of follow-up care. B. The client will implement several relapse-prevention strategies. C. The client will identify triggers that lead to inappropriate behaviors. D. The client will attend aversion therapy groups.

ANS: C During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilic disorder. Pedophilic disorder involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.

When a community health nurse arrives at the home of a client diagnosed with bulimia nervosa, the nurse finds the client on the floor unconscious. The client has a history of using laxatives for purging. To what would the nurse attribute this clients symptoms? A. Increased creatinine and blood urea nitrogen (BUN) levels B. Abnormal electroencephalogram (EEG) C. Metabolic acidosis D. Metabolic alkalosis

ANS: C Excessive vomiting and laxative or diuretic abuse may lead to problems with dehydration and electrolyte imbalance. The nurse should attribute this clients fainting to the loss of alkaline stool due to laxative abuse, which would lead to a relative metabolic acidotic condition.

During family counseling a child states, I just want to surf like other kids. Mom says its okay, but Dad says Im too young. The mother allows surfing when the father is absent. In the structural model of family therapy, what family interactional pattern should the nurse recognize? A. Multigenerational transmission B. Disengagement C. Motherchild subsystem D. Emotional cutoff

ANS: C In this situation the mother and child have formed a subsystem in which they have aligned themselves against the father.

A morbidly obese client is prescribed an anorexiant medication. The nurse should prepare to teach the client about which medication? A. Diazepam (Valium) B. Dexfenfluramine (Redux) C. Lorcaserin (Belviq) D. Pemoline (Cylert)

ANS: C Lorcaserin was approved by the FDA in 2012. It suppresses the appetite by altering various 5-HT2C serotonin receptors. Withdrawal from anorexiants can result in rebound weight gain, lethargy, and depression.

A father tells his 5-year-old, Son, today instead of picking flowers in the outfield, lets try to catch a ball. The child subsequently pays attention and catches a ball. Which principle of building self-esteem has the father implemented? A. A sense of competence B. Unconditional love C. Realistic goals D. Reality orientation

ANS: C Low self-esteem can be the result of not being able to achieve established goals. The father has set for the child a realistic goal that the child accomplished. This should promote self-esteem.

An adolescent, his mother, and his soon-to-be stepfather have been in counseling with the nurse. Which statement by the nurse fosters positive relationships within this new family structure? A. Stepchildren should be consistently disciplined by only one parent. B. It is most important to give your full attention to the childs adjustment since it is most difficult for them. C. Keeping the lines of communication open between everyone in the family is important in establishing healthy relationships. D. Children need to decide who will be their disciplinarian because this new situation will be stressful.

ANS: C Open lines of communication are needed for newly forming families to begin their relationship together and establish a new family structure.

A nursing instructor is teaching about self-concept. Which student statement indicates a need for further instruction? A. Self-concept is the thinking component of the self. B. Self-concept is a system of learned beliefs about self. C. Self-concept is the degree of regard that individuals have for themselves. D. Self-concept is the attitudes and opinions held true about personal existence.

ANS: C Self-esteem, not self-concept, is the degree of regard that individuals have for themselves. This student statement indicates a need for further teaching.

In a family that is in the life cycle stage called The Family with Adolescents, which changes must occur for the family to proceed developmentally? A. Making adjustments within the marital system to meet the responsibilities of parenthood B. Establishing a new identity as a couple by realigning relationships with extended family C. Redefining the level of dependence so that adolescents are provided with greater autonomy D. Reestablishing the bond of the dyadic marital relationship

ANS: C Stage IV of the family life cycle is described as The Family with Adolescents. The task of this stage is to redefine the level of dependence so that adolescents are provided with greater autonomy while parents remain responsive to teenagers dependency needs.

A home health nurse is visiting an Asian family. A married couple, their three children, and the maternal grandparents all live in the home. How should the nurse interpret the presence of the grandparents in the home? A. The parents have diffuse boundaries and have allowed the grandparental subsystem to be present. B. The grandparental subsystem is not successfully managing separation from the parental subsystem. C. Extended family living arrangements are common in some cultures. D. The nuclear family living arrangement is the preferred environment for childrearing.

ANS: C The Asian culture highly respects the elderly. Having the grandparents living in the home is not uncommon in this culture.

A 30-year-old client diagnosed with depression has been exclusively cared for and financially subsidized by his mother since age 17. According to Eriksons theory, the nurse recognizes that the client has been unsuccessful in meeting which developmental task? A. Trust B. Initiative C. Intimacy D. Ego integrity

ANS: C The clients relationship with his mother has contributed to failing completion of the developmental task of intimacy in Eriksons stage of intimacy versus isolation (20 to 30 years). This has resulted in behaviors such as withdrawal, social isolation, aloneness, and the inability to form lasting relationships, leading to his diagnosis of depression.

A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurses first priority? A. Contact the clients psychiatrist. B. Avoid addressing her attention-seeking behavior. C. Lead the client back to her room and assist her to choose appropriate clothing. D. Restrict client to room until visiting hours are over.

ANS: C The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionistic disorder, which is characterized by urges to expose oneself to unsuspecting strangers.

A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? A. Place client in restraints until the aggression subsides. B. Sedate the client with neuroleptic medications. C. Hold clients head steady and apply a helmet. D. Distract the client with a variety of games and puzzles.

ANS: C The most appropriate intervention for head banging is to hold the clients head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the clients head from injury.

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? A. The client will communicate all needs verbally by discharge. B. The client will participate with peers in a team sport by day 4. C. The client will establish trust with at least one caregiver by day 5. D. The client will perform most self-care tasks independently.

ANS: C The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a clients home environment should a nurse associate with the development of this disorder? A. The home environment maintains loose personal boundaries. B. The home environment places an overemphasis on food. C. The home environment is overprotective and demands perfection. D. The home environment condones corporal punishment.

ANS: C The nurse should assess that a home environment that is overprotective and demands perfection may be an influence in the development of anorexia nervosa. In adolescence, distorted eating patterns may represent a rebellion against controlling and demanding parents.

A fatherless, 11-year-old African American girl lives with her grandmother after the death of her mother. Her older stepbrother is very involved in her life. How should the community health nurse view this family constellation, and why? A. Abnormal; the grandmother should be concerned with issues other than childrearing. B. Abnormal; a two-parent household is the most advantageous arrangement for parenting. C. Normal; cultural variations exist in the family life cycle. D. Normal; because of their wisdom, older adults make better parenting figures.

ANS: C The nurse should be aware that cultural differences and specific events may lead to variety in family constellations. This is normal.

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her childs attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mothers concern? A. The physician will probably switch from Ritalin to a central nervous system stimulant. B. The physician may prescribe an antihistamine with the Ritalin to improve effectiveness. C. Your child has probably developed a tolerance to Ritalin and may need a higher dosage. D. Your child has developed sensitivity to Ritalin and may be exhibiting an allergy.

ANS: C The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur.

A high school senior is diagnosed with anorexia nervosa and is hospitalized for severe malnutrition. The treatment team is planning to use behavior modification. What rationale should a nurse identify as the reasoning behind this therapy choice? A. This therapy will increase the clients motivation to gain weight. B. This therapy will reward the client for perfectionist achievements. C. This therapy will provide the client with control over behavioral choices. D. This therapy will protect the client from parental overindulgence.

ANS: C The nurse should identify that behavior modification therapy will be used because it provides the client with control over behavioral choices. Clients diagnosed with anorexia nervosa are often allowed to contract privileges based on weight gain. The client maintains control over eating and exercise.

A clients altered body image is evidenced by claims of feeling fat, even though the client is emaciated. Which is the appropriate outcome criterion for this clients problem? A. The client will consume adequate calories to sustain normal weight. B. The client will cease strenuous exercise programs. C. The client will perceive an ideal body weight and shape as normal. D. The client will not express a preoccupation with food.

ANS: C The nurse should identify that the appropriate outcome for this client is to perceive an ideal body weight and shape as normal. Additional goals include accepting self on the basis of self-attributes instead of appearance and to realize that perfection is unrealistic.

A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change? A. The client gains 2 pounds in 1 week. B. The client focuses conversations on nutritious food. C. The client demonstrates healthy coping mechanisms that decrease anxiety. D. The client verbalizes an understanding of the etiology of the disorder.

ANS: C The nurse should identify that when a client uses healthy coping mechanisms that decrease anxiety, positive behavioral change is demonstrated. Stress and anxiety can increase bingeing, which is followed by inappropriate compensatory behaviors.

A group of nurses are discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which of these nurses will probably be most effective with these clients? A. The nurse who understands the importance of three balanced meals a day B. The nurse who permits children to have dessert only after finishing the food on their plate C. The nurse who refuses to engage in power struggles related to food consumption D. The nurse who grew up poor and frequently did not have enough food to eat

ANS: C The nurse who refuses to engage in power struggles related to food consumption will probably be most effective when dealing with clients diagnosed with eating disorders. Because of this attitude the nurse recognizes that the real issues have little to do with food or eating patterns. The nurse will be able to focus on the control issues that precipitated these behaviors.

Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.

ANS: C The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern.

A nurse is seeing a client in an outpatient clinic for treatment of anorexia nervosa. Which is the most appropriate, correctly written short-term outcome for this client? A. The client will use stress-reducing techniques to avoid purging. B. The client will discuss chaos in personal life and be able to verbalize a link to purging. C. The client will gain 2 pounds prior to the next weekly appointment. D. The client will remain free of signs and symptoms of malnutrition and dehydration.

ANS: C The symptoms of anorexia nervosa do not include purging. Correctly written outcomes must be client centered, specific, realistic, and measurable and also include a time frame.

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-mL bottle. The label reads 20 mg/5 mL. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense? A. 25 mL B. 20 mL C. 15 mL D. 10 mL

ANS: C Twenty mg of Prozac multiplied by three results in the calculated 60-mg daily dose ordered by the physician. Each 5 mL contains 20 mg. Five mL multiplied by three equals the liquid dosage of 15 mL.

18. A client is angry because her husband has forgotten their anniversary. The following week, the client is still unwilling to discuss this with her husband because she is afraid she will lose control. How should the nurse interpret this clients means of coping with anger? A. Coping by attacking B. Coping by surrendering C. Coping by avoiding D. Coping by belittling

ANS: C When coping by avoidance, differences are never acknowledged openly. The individual who disagrees avoids discussing it for fear that the other person will withdraw love or approval or become angry in response to the disagreement. Avoidance also occurs when an individual fears loss of control of his or her temper.

A home health nurse visits an 18-year-old client who lives with his mother. The client has been assessed as having low self-esteem. The nurse refers the client for individual counseling. During the next home visit, which assessed client behavior clearly indicates treatment success? A. The client wants to buy a dog but has not yet asked his mothers permission. B. The client asks his mother for permission to buy a dog. C. The client tells his mother he plans to buy a dog. D. The client buys a dog and hides it in the garage.

ANS: C When the client tells his mother he plans to buy a dog, he is making decisions and taking on responsibilities. This indicates an increase in self-confidence and therefore self-esteem.

A nurse responsible for conducting group therapy on an eating disorder unit schedules the sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time? A. To shift the clients focus from food to psychotherapy B. To prevent the use of maladaptive defense mechanisms C. To promote the processing of anxiety associated with eating D. To focus on weight control mechanisms and food preparation

ANS: C When the nurse schedules group therapy immediately after meals, the nurse is addressing the emotional issues related to eating disorders that must be resolved if these maladaptive responses are to be eliminated.

The nurse is working with a 15-year-old client suffering from low self-esteem. According to Eriksons psychosocial developmental theory, which factor has most probably influenced this clients self-esteem? A. Regret over life choices B. Lack of personal concern for others C. Inconsistent, overly harsh, or absent parental discipline D. Parental labeling of the child as good regardless of their behavior.

ANS: C When there is inconsistent, overly harsh, or absent discipline in the home, it is difficult for a teenager to develop the independent sense of self needed to achieve a positive self-esteem.

A 30-year-old client seeking therapy states, My mom cries when she is not included in all my social activities and thinks of my friends as her own. How would the nurse describe the boundaries between this familys parent and child subsystems? A. The boundaries are rigid. B. The boundaries are restructured. C. The boundaries are enmeshed. D. The boundaries are disengaged.

ANS: C With enmeshed boundaries, family members lack individuation and experience exaggerated connectedness. The clients mother is trying to prevent independence by generating feelings of guilt.

A couple has been married for 20 years. They argue constantly, belittle feelings, and continuously contradict each other. During a therapy session, the nurse documents Marital schism. What does the nurse mean by this documentation? A. The couple has a compatible marriage relationship. B. The husband has a dominant relationship over the wife. C. The couple has an enmeshed relationship. D. The couple has an incompatible marriage relationship.

ANS: D A marital schism is a state of chronic disequilibrium and discord. This describes this couples marriage.

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders? A. These programs help clients correct distorted body image. B. These programs address underlying client anger. C. These programs help clients manage uncontrollable behaviors. D. These programs allow clients to maintain control.

ANS: D Behavior modification programs are the treatment of choice for clients diagnosed with eating disorders because the programs allow clients to maintain control. Issues of control are central to the etiology of these disorders. Behavior modification techniques aid in restoring healthy body weight.

A nurse enters an inpatient room and finds the family disagreeing about the clients living arrangements after discharge. Which information should the nurse provide when teaching techniques to resolve family conflicts? A. All family members should use past incidents to make their point. B. One family member should act as a gatekeeper in order to avoid family confrontation. C. One family member should act as a compromiser to preserve harmony in the family system. D. All family members should respect differing opinions and use compromise and negotiation.

ANS: D Functional families allow and respect differences among members. They learn to handle differences and conflict through negotiation and compromise.

A client is diagnosed with hypoactive sexual desire disorder. Which of the following are recognized as treatment options? A. Testosterone injections B. Couples therapy C. Cognitive therapy D. All of the above.

ANS: D Hypoactive sexual desire disorder has been treated in men and women with testosterone. Cognitive behavioral therapies and relationship therapies have been identified as most beneficial when combined together. Couples therapy has been identified as a beneficial focus when partner incompatibility with regard to sexual desire is identified as an issue.

During family counseling a husband states, Every time my wife and I discuss child discipline, we get into shouting matches. The nurse instructs the couple to shout at each other for 2 weeks on Tuesdays and Thursdays for 30 minutes. What intervention is the nurse using? A. Reframing B. Restructuring the family C. Expressive psychotherapy D. Paradoxical intervention

ANS: D In a paradoxical intervention, the therapist requests the family to continue the maladaptive behavior. This removes control over the behavior from the family to the therapist. Clients are made more aware of the defeating behavior and this can lead to behavioral change.

A nursing instructor is teaching about pharmacological treatments for attention deficit-hyperactivity disorder (ADHD). Which information about atomoxetine (Strattera) should be included in the lesson plan? A. Strattera, unlike methylphenidate (Ritalin), is a central nervous system depressant. B. When taking Strattera, a client should eliminate all red food coloring from the diet. C. Strattera will be a life-long intervention for clients diagnosed with this disorder. D. Strattera, unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor.

ANS: D Strattera is a selective norepinephrine reuptake inhibitor. Ritalin is classified as a stimulant. The exact mechanism by which these drugs produce a therapeutic effect in ADHD is unknown.

A 40-year-old client lives with her parents. She has a high school diploma and works at a low-paying job. Her parents give her a weekly allowance to supplement her income. How should the nurse classify their client- parent boundaries? A. As loose B. As rigid C. As flexible D. As enmeshed

ANS: D The client and her parents are overly dependent. The parents control too many aspects of the clients life. Their boundaries are blurred so that it is hard for the client to differentiate her wants and needs from those of her parents. The clientparent boundaries are enmeshed.

A depressed 21-year-old client has lived with his mother ever since the death of his father 3 years ago. After the client received a college acceptance, the mother repeatedly states, Thats wonderful. Ill be fine all alone. How would the nurse interpret the mothers statements? A. The mother is withholding supportive messages. B. The mother is expressing denigrating remarks. C. The mother is communicating indirectly. D. The mother is using double-bind communication.

ANS: D The clients mother says she is fine with him going away to college but then tries to make him feel guilty about her being left alone. The client is in a no-win situation because his mother has given a mixed messagea double- bind communication.

When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of sensate focus exercises? A. To initiate immediate orgasm B. To reduce anxiety by eliminating physical touch C. To focus on touching breasts and genitals D. To reduce goal-oriented demands of intercourse

ANS: D The expected outcome of sensate focus exercises is to reduce goal-oriented demands of intercourse. Sensate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.

A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed? A. STDs carry strong connotations of illicit sex and considerable social stigma. B. STDs can cause insanity. C. The diagnosis of HIV can generate hopelessness and helplessness. D. Antibiotics administered in the early stages can cure all STDs.

ANS: D The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.

Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability? A. The client can perform some self-care activities independently. B. The client has advanced speech development. C. Other than possible coordination problems, the clients psychomotor skills are not affected. D. The client communicates wants and needs by acting out behaviors.

ANS: D The nurse should identify that a client diagnosed with severe intellectual disability may communicate wants and needs by acting out behaviors. Severe intellectual disability indicates an IQ between 20 and 34. Individuals diagnosed with severe intellectual disability require complete supervision and have minimal verbal skills and poor psychomotor development.

A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual disability (ID). Which student statement indicates that further instruction is needed? A. These clients can work in a sheltered workshop setting. B. These clients can perform some personal care activities. C. These clients may have difficulties relating to peers. D. These clients can successfully complete elementary school.

ANS: D The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate ID are capable of academic skill up to only a second-grade level. Moderate ID reflects an IQ range of 35 to 49.

An 8-year-old client diagnosed with attention deficit-hyperactivity disorder (ADHD) was admitted 5 days ago for management of temper tantrums. What would be a priority nursing intervention during the termination phase of the nurseclient relationship? A. Set a contract with the client to limit acting-out behaviors while hospitalized. B. Teach the importance of taking fluoxetine (Prozac) consistently, even when feeling better. C. Discuss behaviors that are and are not acceptable on the unit. D. Ask the client to demonstrate learned coping skills without direction from the nurse.

ANS: D The priority nursing intervention during the termination phase of the nurseclient relationship should include encouraging the client to demonstrate the coping skills learning during the working phase of the nurseclient relationship.

In what way should a nurse expect a school-aged child to gain positive self-esteem, according to Eriksons psychosocial developmental stages? A. Through basic need fulfillment and environmental predictability B. Through exploration and experimentation, resulting in self-confidence in ability to perform C. Through positive reinforcement of creativity and recognition of performance D. Through receiving recognition when learning, competing, and performing successfully

ANS: D The school-aged child develops self-confidence by learning, competing, and performing successfully and receiving recognition from significant others, peers, and acquaintances.

A potential Olympic figure skater collapses during practice and is hospitalized for severe malnutrition. Anorexia nervosa is diagnosed. Which client statement best reflects a theory about the underlying etiology of this disorder? A. I was just trying to be like everyone else. B. All the skaters on the team are following an approved 1,200-calorie diet. C. When I lose skating competitions, I also lose my appetite. D. I am angry at my mother. I can get her approval only when I win competitions.

ANS: D This client statement reflects a possible underlying etiology of anorexia nervosa. The client is expressing feelings about family dynamics that may have influenced the development of this disorder. Families who are overprotective and perfectionistic can contribute to a family members development of anorexia nervosa.

A client diagnosed with anorexia nervosa stopped eating 5 months ago and lost 25% of total body weight. Which subjective client response would the nurse assess to support this medical diagnosis? A. I do not use any laxatives or diuretics to lose weight. B. I am losing lots of hair. Its coming out in handfuls. C. I know that I am thin, but I refuse to be fat! D. I dont know why people are worried. I need to lose this weight.

ANS: D When the client states, I dont know why people are worried. I need to lose this weight, the client is exhibiting the subjective response of ineffective denial. This client is minimizing symptoms and is unable to admit impact of the disease on life patterns. The client does not perceive personal relevance of symptoms or danger.