CH 26 - Crisis & Disaster, Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders 30Qw/exp, Varcarolis 26: Crisis and Disaster, Varcarolis Chapter 16 Trauma, stressor related, and Dissociative Disorders, Chapter 22: Substance Related and Ad...

Which event leads to the development of a situational crisis in patients? a. Loss of a job b. Birth of a child c. Natural disaster d. Physical assault

a

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

b

The nurse manager instructed the nurse to conduct crisis intervention for a patient whose parents died in an accident. How should the nurse start the crisis intervention for the patient? a. By teaching mindfulness to the patient b. By establishing rapport with the patient c. By planning interventions for the patient d. By understanding the feelings of the patient

b

What is the best description of a psychiatric advance directive plan? a. Outpatient care with the goal of preventing hospitalization b. Proactive method of addressing a crisis situation before it occurs c. Legal, written statement regarding a person's wishes regarding medical treatment d. Continuous 24-hour observation and supervision for those not requiring inpatient services

b

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

b

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

bc

Symptoms of acute ___ include feelings of numbness, confusion, and incoherence.

confusion

Patients experiencing ___ have chronic low self-esteem, post-trauma syndrome, impaired social interaction, and acute confusion.

crisis

The symptoms of ___ syndrome are denial, hypervigilance, and panic.

post-trauma

The symptoms of chronic low ___ are self-hatred and depression.

self-esteem

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

situational

A nurse prepares to teach important medication information to a patient of Mexican heritage. How should the nurse manage the teaching environment? a. Stand very close to the patient while teaching. b. Maintain direct eye contact with the patient while teaching. c. Maintain a neutral emotional tone during the teaching session. d. Sit 4 feet or more from the patient during the teaching session.

A Latin American cultures use close personal space, closer than many other minority groups. Standing very close to the patient frequently indicates acceptance. Direct eye contact should not be prolonged with this patient. Persons of this cultural heritage have high emotionality.

All of the following substances are considered central nervous system stimulants, except A. cocaine B. caffeine C. methadone D. methamphetamine

All of the following substances are considered central nervous system stimulants, except C. methadone

A patient who has been hospitalized for 3 days with a serious mental illness says, "I've got to get out of here and back to my job. I get 60 to 80 messages a day, and I'm getting behind on my email correspondence." What is this patient's perspective about health and illness? a. Fateful, magical b. Eastern, holistic c. Western, biomedical d. Harmonious, religious

C The Western biomedical perspective holds the belief that sick people should be as independent and self-reliant as possible. Self-care is encouraged.

Which of the drugs used by a polysubstance abuser is most likely to be responsible for withdrawal symptoms requiring both medical intervention and nursing support? A. Opiates B. Marijuana C. Barbiturates D. Hallucinogens

C. Barbiturates

What is the ethical obligation of the nurse who has seen a peer divert a narcotic compared with the ethical obligation when the nurse observes a peer to be under the influence of alcohol? A. The nurse should immediately report the peer who is diverting narcotics and should defer reporting the alcohol-using nurse until a second incident takes place. B. Neither should be reported until the nurse has collected factual evidence. C. No report should be made until suspicions are confirmed by a second staff member. D. Supervisory staff should be informed as soon as possible in both cases.

D. Supervisory staff should be informed as soon as possible in both cases.

Benzodiazepines are useful for treating alcohol withdrawal because they A. block cortisol secretion. B. increase dopamine release. C. decrease serotonin availability. D. bind to ã-aminobutyric acid-benzodiazepine receptors.

D. bind to ã-aminobutyric acid-benzodiazepine receptors

A client has been using cocaine intranasally for 4 years. Two months ago she started freebasing. For the past week she has locked herself in her apartment and has used $8000 worth of cocaine. When brought to the hospital she was unconscious. Nursing measures should include A. induction of vomiting. B. administration of ammonium chloride. C. monitoring of opiate withdrawal symptoms. D. observation for hyperpyrexia and seizures.

D. observation for hyperpyrexia and seizures.

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

The nurse is having difficulty terminating the relationship. The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient shows no need for continuing support. The scenario does not describe dependency needs.

Which of the following complications of substance abuse is considered life threatening? A. Drug craving B. Hallucinogen flashbacks C. Delirium tremens D. Opioid withdrawal

Which of the following complications of substance abuse is considered life threatening? C. Delirium tremens Side note: Delirium tremens can occur when you stop drinking alcohol after a period of heavy drinking, especially if you do not eat enough food. Symptoms include: *Seizures* (may occur without other symptoms of DTs; Most common in first 12 - 48 hours after last drink) Body tremors Changes in mental function Agitation, irritability Confusion, disorientation Hallucinations Symptoms of alcohol withdrawal

Which of the following medications is frequently used to detoxify a client in alcohol withdrawal? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Clonidine (Capapres) D. Sertaline (Zoloft)

Which of the following medications is frequently used to detoxify a client in alcohol withdrawal? A. Diazepam (Valium) Side note: Haldol (haloperidol) is indicated for use in the treatment of schizophrenia. Clonidine hydrochloride is indicated for the treatment of HTN as well as ADHD as monotherapy and as adjunctive therapy to stimulant medications. Zoloft (sertraline hydrochloride) is indicated for the treatment of Major Depressive Disorder, OCD, Panic Disorder, PTSD, and Social Anxiety Disorder

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

b. Teaching stress reduction techniques to a first-year college student Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary care.

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

c

When the patient begins to sob uncontrollably and speech becomes so incoherent that the patient is unable to give the nurse any information, the immediate interventions will focus on which of the following? a. Securing hospital admission b. Contacting a family member or close friend c. Lowering the patient's anxiety level from severe to moderate d. Assisting the patient to identify new effective coping strategies

c

Which best describes the principle of crisis intervention? a. Support that includes all people who are available that can be depended upon during the time of crisis b. An action that promotes mental health and reduces mental illness to decrease the incidence of crisis c. A directive, time-limited, and goal-directed strategy designed to assist individuals who are experiencing crisis d. A technique in which those affected by a crisis or disaster come together to share thoughts, feelings, and experiences

c

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

c. Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. There is no classification called reactive. Adventitious crises occur when disasters, such as natural disasters (e.g., floods, hurricanes), war, or violent crimes, disrupt coping.

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

c. National Incident Management System (NIMS) The National Incident Management System (NIMS) provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

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

c. Situational A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

d. Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

___ is an intervention that may be used following a crisis in which those affected come together to share thoughts, feelings, and experiences.

debriefing

___ crisis is caused by events such as leaving home for education, retirement, and the death of a parent.

maturational

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists?

situational

___ crisis is caused when the patient feels abandoned or when a loved one passes away. It can also be caused by exposure to severe physical and mental illness like assaults, and abuse.

situational

An unconscious client is admitted to the emergency department. The admitting diagnosis is "rule out opiate overdose." Which item of assessment data would be most consistent with opiate overdose? A. Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min B. Blood pressure, 120/80 mm Hg; pulse, 84 beats/min; respirations, 20 breaths/min C. Blood pressure, 140/90 mm Hg; pulse, 76 beats/min; respirations, 24 breaths/min D. Blood pressure, 180/100 mm Hg; pulse, 72 beats/min; respirations, 28 breaths/min

A. Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min

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

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

The nurse should be particularly alert to expression of psychological distress through physical symptoms among patients whose cultural beliefs include (Select all that apply) a. mental illness reflects badly on the family. b. mental illness shows moral weakness. c. intergenerational conflict is common. d. the mind, body, and spirit are merged. e. food choices influence one's health.

A, B, D Physical symptoms are seen as more acceptable in cultural groups in which interdependence and harmony of the group are emphasized. Mental illness is often perceived as reflecting a failure of the entire family. In groups in which mental illness is seen as a moral weakness and both the individual and family are stigmatized, somatization of mental distress is better accepted. In groups in which mind, body, and spirit are holistically perceived, somatization of psychological distress is common. Somatization and food are not commonly related. Intergenerational conflict has not been noted as a risk factor for somatization.

Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? A. " I attend my therapy sessions regularly." B. " Those intrusive memories are hidden for a reason and should stay hidden." C. " Keeping busy is the key to getting mentally healthy." D. " I've agreed to move in with my parents so I'll get the support I need."

A. " I attend my therapy sessions regularly."

A client was in an automobile accident. Although he has the odor of alcohol on his breath, his speech is clear and he is alert and answers questions posed to him. The law enforcement officer requests that the emergency department staff draw a blood sample for blood alcohol level determination. The level is determined to be 0.30 mg%. What conclusion can be drawn? A. The client has a high tolerance to alcohol. B. The client ate a high-fat meal before drinking. C. The client has a decreased tolerance to alcohol. D. No conclusions can be drawn from the data.

A. The client has a high tolerance to alcohol.

A client who is dependent on alcohol and drinks several six-packs of beer daily tells the nurse "Alcohol is no problem to me. I can quit anytime I want to." The nurse can assess this statement as indicating A. denial. B. projection. C. rationalization. D. reaction formation.

A. denial.

Symptoms that would signal opioid withdrawal include A. lacrimation, rhinorrhea, dilated pupils, and muscle aches. B. illusions, disorientation, tachycardia, and tremors. C. fatigue, lethargy, sleepiness, and convulsions. D. synesthesia, depersonalization, and hallucinations.

A. lacrimation, rhinorrhea, dilated pupils, and muscle aches.

The only class of commonly abused drugs that has a specific antidote is A. opiates. B. hallucinogens. C. amphetamines. D. benzodiazepines.

A. opiates.

Nursing assessment of an alcohol-dependent client 6 to 12 hours after the last drink would most likely reveal the presence of A. tremors. B. seizures. C. blackouts. D. hallucinations.

A. tremors.

16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

A psychoeducational session will discuss medication management for a culturally diverse group of patients. Group participants are predominantly members of minority cultures. Of the four staff nurses below, which nurse should lead this group? a. Very young registered nurse b. Older, mature registered nurse c. Newly licensed registered nurse d. A registered nurse who is very thin

B Persons of minority cultures value age and wisdom. Persons with a Western worldview tend to value youth. An older, mature registered nurse would be the most credible leader of this group. The nurse's size has no bearing on credibility.

Which drug is most apt to have been ingested by a young woman who comes to the emergency department with the report that although she has no recollection of the incident, she believes she was sexually assaulted at a party? A. LAAM B. GHB C. ReVia D. Clonidine

B. GHB

Cocaine exerts which of the following effects on a client? A. Stimulation after 15 to 20 minutes B. Stimulation and anesthetic effects C. Immediate imbalance of emotions D. Paranoia

B. Stimulation and anesthetic effects

The care plan of a male patient diagnosed with a dissociative disorder includes the nursing diagnosis ineffective coping. Which behavior demonstrated by the patient supports this nursing diagnosis? A. Has no memory of the physical abuse he endured. B. Using both alcohol and marijuana C. Often reports being unaware of surroundings. D. Reports feelings of "not really being here"

B. Using both alcohol and marijuana

A person who covertly supports the substance-abusing behavior of another is called a(n) A. patsy. B. enabler. C. participant. D. minimizer.

B. enabler.

A client brought to the emergency department at the university hospital after PCP ingestion tries to run up and down the hallway. The nursing intervention that would be most therapeutic is A. taking him to the gym on the psychiatric unit. B. obtaining an order for seclusion and close observation. C. assigning a psychiatric technician to "talk him down." D. administering naltrexone as needed per hospital protocol.

B. obtaining an order for seclusion and close observation.

A Vietnamese patient's family reports that the patient has wind illness. Which menu selection will be most helpful for this patient? a. Iced tea b. Ice cream c. Warm broth d. Gelatin dessert

C Wind illness is a culture-bound syndrome found in the Chinese and Vietnamese population. It is characterized by a fear of cold, wind, or drafts. It is treated by keeping very warm and avoiding foods, drinks, and herbs that are cold. Warm broth would be most in sync with the patient's culture and provide the most comfort. The distracters are cold foods.

Why is the study of culture so important for psychiatric nurses in the United States? (Select all that apply.) a. Psychiatric nurses often practice in other countries. b. Psychiatric nurses must advocate for the traditions of the Western culture. c. Cultural competence helps protect patients from prejudice and discrimination. d. Patients should receive information about their illness and treatment in terms they understand. e. Psychiatric nurses often interface with patients and their significant others over a long period of time.

C, D, E One purpose of cultural competence is for the psychiatric nurse to relate and explain information about the patient's illness and treatment in an understandable way, incorporating the patient's own beliefs and values. A fundamental aspect of nursing practice is advocacy. Cultural competence promotes recognition of prejudices in care, such as stigma and misdiagnosis. Psychiatric nurses often interface with patients and families over years and in community settings.

A teaching need is revealed when a client taking disulfiram states A. "I usually treat heartburn with antacids." B. "I take ibuprofen or acetaminophen for headache." C. "Most over-the-counter cough syrups are OK for me to use." D. "I have had to give up using aftershave lotion."

C. "Most over-the-counter cough syrups are OK for me to use."

Which statement accurately describes the effects of emotional trauma on the individual physically? A. Emotional trauma is a distinct category and unrelated to physical problems. B. The physical manifestations of emotional trauma are usually temporary C. Emotional trauma is often manifested as physical symptoms D. Patients are more aware of the physical problems caused by trauma

C. Emotional trauma is often manifested as physical symptoms

Which goal should be addressed initially when providing care for 10-year-old Harper who is diagnosed with Posttraumatic stress disorder? A. Harper will be able to identify feelings through the use of play therapy. B. Harper and her parents will have access to protective resources available through social services. C. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts. D. Harper and her parents will demonstrate an understanding of the human response to traumatic events.

C. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts

While helping an addicted individual plan for ongoing treatment, which of the following interventions is the first priority for a safe recovery? A. Securing ongoing support from at least two family members. B. The client needs to be employed. C. The client strives to maintain abstinence. D. A regular schedule of appointments with a primary care provider.

C. The client strives to maintain abstinence.

An appropriate long-term goal/outcome for a recovering substance abuser would be that the client will A. discuss the addiction with significant others. B. state an intention to stop using illegal substances. C. abstain from the use of mood-altering substances. D. substitute a less-addicting drug for the present drug.

C. abstain from the use of mood-altering substances.

The most helpful message to transmit about relapse to the recovering alcoholic client is that lapses A. are an indicator of treatment failure. B. are caused by physiological changes. C. result from lack of good situational support. D. can be learning situations to prolong sobriety.

C. result from lack of good situational support.

A patient in the emergency department shows a variety of psychiatrical symptoms, including restlessness and anxiety. The patient says, "I feel sad because evil spirits have overtaken my mind." Which worldview is most applicable to this individual? a. Eastern/balance b. Southern/holistic c. Western/scientific d. Indigenous/harmony

D Persons of an indigenous worldview believe disease results from a lack of personal, interpersonal, environmental, or spiritual harmony and that evil spirits exist. The holism of body-mind-spirit is a key component of this view. If one believes an evil spirit has taken control, distress results. Western and Eastern worldviews do not embrace spirits.

The school nurse has been alerted to the fact that an 8 year old boy routinely playacts as a police officer "locking up" other children on the playground to the point where the children get scared. The nurse recognizes that this behavior is most likely an indication of: A. the need to dominate others B. Inventing traumatic events. C. the need to develop close relationships D. A potential symptom of traumatization

D. a potential symptom of traumatization

The term tolerance, as it relates to substance abuse, refers to A. use of a substance beyond acceptable societal norms. B. the additive effects achieved by taking two drugs with similar actions. C. the signs and symptoms that occur when an addictive substance is withheld. D. the need to take larger amounts of a substance to achieve the same effects.

D. the need to take larger amounts of a substance to achieve the same effects.

A syndrome that occurs after stopping use of a drug is A. amnesia. B. tolerance. C. enabling. D. withdrawal.

D. withdrawal.

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

Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents. Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

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

a

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

ade

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

d

A nurse manager instructs a nurse to perform crisis intervention for an acute crisis. Which step should be the priority while conducting secondary care for the patient? a. Focus on the safety of the patient. b. Discuss facts and incidents with the patient. c. Prevent the emotional disruption of the patient. d. Demonstrate assertiveness skills to the patient.

a

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

c

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

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

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

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

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

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

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

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

An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies?

hopelessness

After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred?

maturational

Symptoms of impaired ___ ___ include feelings of isolation and little or no social support.

social interaction

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

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

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

Powerlessness The patient describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not altered at this point.

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

a

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

b

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

d. Ineffective role performance related to distress from false accusations This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor's crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

Which questions should the nurse ask to determine an individual's worldview? (Select all that apply.) a. What is more important: the needs of an individual or the needs of a community? b. How would you describe an ideal relationship between individuals? c. How long have you lived at your present residence? d. Of what importance are possessions in your life? e. Do you speak any foreign languages?

A, B, D The answers provide information about cultural values related to the importance of individuality, material possessions, relational connectedness, community needs versus individual needs, and interconnectedness between humans and nature. These will assist the nurse to determine a patient's worldview.

An experienced psychiatric nurse plans to begin a new job in a community-based medication clinic. The clinic sees culturally diverse patients. Which action should the nurse take first to prepare for this position? a. Investigate cultural differences in patients' responses to psychotropic medications. b. Contact the clinical nurse specialist for guidelines regarding cultural competence. c. Examine the literature on various health beliefs of members of diverse cultures. d. Complete an online continuing education offering about psychopharmacology.

A An experienced nurse working on a mental health inpatient unit would be familiar with the action and side effects of most commonly prescribed psychotropic medications. However, because the clinic serves a culturally diverse population, reviewing cultural differences in patients' responses to these medications is helpful and vital to patient safety. The distracters identify actions the nurse would take later.

Which viewpoint of an Asian American family will most affect decision making about care? a. The father is the authority figure. b. The mother is head of the household. c. Women should make their own decisions. d. Emotional communication styles are desirable.

A Asian American families traditionally place the father in the position of power as the head of the household. Mothers, as well as other women, are usually subservient to fathers in these cultures. Asian Americans are more likely to be reserved

The sibling of an Asian American patient tells the nurse, "My sister needs help for pain. She cries from the hurt." Which understanding by the nurse will contribute to culturally competent care for this patient? Persons of an Asian American heritage a. often express emotional distress with physical symptoms. b. will probably respond best to a therapist who is impersonal. c. will require prolonged treatment to stabilize these symptoms. d. should be given direct information about the diagnosis and prognosis

A Asian Americans commonly express psychological distress as a physical problem. The patient may believe psychological problems are caused by a physical imbalance. Treatment will likely be short. The patient will probably respond best to a therapist who is perceived as giving. Asian Americans usually have strong family ties and value hope more than truth.

A nurse speaks with family members of a Chinese American parent recently diagnosed with major depressive disorder. Which comment by the nurse will the family find most comforting? "The nursing staff will a. take good care of your parent." b. pray with your parent several times a day." c. teach your parent important self-care strategies." d. educate your parent about safety information regarding medication."

A Chinese Americans hold an Eastern (balance) worldview. Persons who are ill or need health care are vulnerable and need protection. The family will find comfort in a nurse's statement that good care will be provided. The distracters apply to persons with a Western or indigenous worldview.

The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics? a. Patients of different cultural groups may metabolize medications at different rates. b. Metabolism of psychotropic medication is consistent among various cultural groups. c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications. d. It is important to provide patients with oral and written literature about their psychotropic medications.

A Cytochrome enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication: hepatic function influences metabolism rates.

A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at all. What understanding will improve the nurse's planning? These patients are a. members of cultural groups that have a different view of time. b. immature and irresponsible in health care matters. c. acting-out feelings of anger toward the system. d. displaying passive-aggressive tendencies.

A Hispanic Americans and Native Americans traditionally treat time in a way unlike the Western culture. They tend to be present-oriented- that is, they value the current interaction more than what is to be done in the future. If engaged in an activity, for example, they may simply continue the activity and appear later for an appointment. Understanding this, the nurse can avoid feelings of frustration and anger when the nurse's future orientation comes into conflict with the patient's present orientation.

A psychiatric nurse leads a medication education group for Hispanic patients. This nurse holds a Western worldview and uses pamphlets as teaching tools. Groups are short and concise. After the group, the patients are most likely to believe a. the nurse was uncaring. b. the session was effective. c. the teaching was efficient. d. they were treated respectfully.

A Hispanic individuals usually value relationship behaviors. Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task.

A Chinese American patient diagnosed with an anxiety disorder says, "My problems began when my energy became imbalanced." The nurse asks for the patient's ideas about how to treat the imbalance. Which comment would the nurse expect from this patient? a. "My family will bring special foods to help me get well." b. "I hope my health care provider will prescribe some medication to help me." c. "I think I would benefit from talking to other patients with a similar problem." d. "I would like to have a native healer perform a ceremony to balance my energy."

A The concept of energy imbalance as a source of illness is an explanatory model familiar to Asian cultures.

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

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

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

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

18. At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: a. codependence. b. assertiveness c. role reversal d. homeostasis.

ANS: A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

13. During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

ANS: A During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

11. A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

ANS: A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjectioninvolves incorporating a quality of another person or group into one's own personality.

23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

28. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine - National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

ANS: A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

30. Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will: a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

17. When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

2. The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply) a. rehearsing techniques to handle anticipated stressful situations. b. advising the patient to accept residential treatment if relapse occurs. c. assisting the patient to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

10. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.

ANS: B A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

9. A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers."

ANS: B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

6. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n): a. narcotic analgesic, such as hydromorphone (Dilaudid). b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium). c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

19. In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

ANS: B The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

27. An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

24. Symptoms of withdrawal from opioids for which the nurse should assess include: a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

ANS: B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, C, F The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

14. The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should: a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

ANS: C Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.

25. A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: a. cross-tolerance. b. substance abuse c. substance addiction. d. substance intoxication.

ANS: C Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.

4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

4. A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

ANS: C, D The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

26. Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use. (Educators may alter this question to multiple answers if desired.)

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

22. A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

8. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

21. Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiologic stability.

ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.

29. A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply) a. administration of naloxone (Narcan). b. vitamin B12 and folate supplements. c. restoring nutritional integrity. d. management of heart rate. e. environmental safety.

ANS: D, E Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

Which health care worker should be referred for critical incident stress debriefing? a. A nurse who works at an oncology clinic where patients receive chemotherapy b. A case manager whose patients have serious mental illness and are cared for at home c. A health care employee who worked 12 hours at the information desk of a critical care unit d. An emergency medical technician (EMT) who treated victims of a car bombing at a mall

An emergency medical technician (EMT) who treated victims of a car bombing at a mall Although each of the individuals mentioned experiencing job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to trauma victims.

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

d

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

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

A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support. a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b. "Who can be helpful to you during this time?" Only the answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

A patient is seen in the clinic for superficial cuts on both wrists. Initially the patient paces and sobs but after a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking: a. "Tell me why you were crying." b. "How did your wrists get injured?" c. "How can I help you feel more comfortable?" d. "What was happening when you started feeling this way?"

d

A nurse wants to engage an interpreter for a severely anxious 21-year-old male who immigrated to the United States 2 years ago. Of the four interpreters below who are available and fluent in the patient's language, which one should the nurse call? a. 65-year-old female professional interpreter b. 24-year-old male professional interpreter c. A member of the patient's family d. The patient's best friend

B A professional interpreter will be most effective because he/she will be able to interpret both language and culture. When an interpreter is engaged, the interpreter should be matched to the patient as closely as possible in gender, age, social status, and religion. Interpreters should not be relatives or friends of the patient. The stigma of mental illness may prevent the openness needed during the encounter.

Which intervention best demonstrates that a nurse correctly understands the cultural needs of a hospitalized Asian American patient diagnosed with a mental illness? a. Encouraging the family to attend community support groups b. Involving the patient's family to assist with activities of daily living c. Providing educational pamphlets to explain the patient's mental illness d. Restricting homemade herbal remedies the family brings to the hospital

B The Asian community values the family in caring for each other. The Asian community uses traditional medicines and healers, including herbs for mental symptoms. The Asian community describes illness in somatic terms. The Asian community attaches a stigma to mental illness, so interfacing with the community would not be appealing.

A nurse cares for a first-generation American whose family emigrated from Germany. Which worldview about the source of knowledge would this patient likely have? a. Knowledge is acquired through use of affective or feeling senses. b. Science is the foundation of knowledge and proves something exists. c. Knowledge develops by striving for transcendence of the mind and body. d. Knowledge evolves from an individual's relationship with a supreme being.

B The European-American perspective of acquiring knowledge evolves from science. The distracters describe the beliefs of other cultural groups.

A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says, "I feel stupid. I've never had a good job. I don't help my people." Which nursing diagnosis applies? a. Risk for other-directed violence b. Chronic low self-esteem c. Deficient knowledge d. Social isolation

B The patient has given several indications of chronic low self-esteem.

A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurse's best action? a. Move the picture so it is beside a window. b. Send the picture to the business office safe. c. Leave the picture where the patient placed it. d. Send the picture home with the patient's family.

C Cultural heritage is expressed through language, works of art, music, dance, customs, traditions, diet, and expressions of spirituality. This patient's prominent placement of the picture is an example of expression of cultural heritage and spirituality. The nurse should not move it unless the patient's safety is jeopardized.

A group activity on an inpatient psychiatric unit is scheduled to begin at 1000. A patient, who was recently discharged from U.S. Marine Corps, arrives at 0945. Which analysis best explains this behavior? a. The patient wants to lead the group and give directions to others. b. The patient wants to secure a chair that will be close to the group leader. c. The military culture values timeliness. The patient does not want to be late. d. The behavior indicates feelings of self-importance that the patient wants others to appreciate.

C Culture is more than ethnicity and social norms. it includes religious, geographic, socioeconomic, occupational, ability- or disability-related, and sexual orientation-related beliefs and behaviors. In this instance, the patient's military experience represents an aspect of the patient's behavior. The military culture values timeliness. The distracters represent misinterpretation of the patient's behavior and have no bearing on the situation.

A Haitian patient diagnosed with major depressive disorder tells the nurse, "There's nothing you can do. This is a punishment. The only thing I can do is see a healer." The culturally aware nurse assesses that the patient a. has delusions of persecution. b. has likely been misdiagnosed with depression. c. may believe the distress is the result of a curse or spell. d. feels hopeless and helpless related to an unidentified cause.

C Individuals of African American or Caribbean cultures who have a fatalistic attitude about illness may believe they are being punished for wrongdoing or are victims of witchcraft or voodoo. They may be reticent to share information about curses with therapists. No data are present in the scenario to support delusions. Misdiagnosis more often labels a patient with depression as having schizophrenia.

Which communication strategy would be most effective for a nurse to use during an assessment interview with an adult Native American patient? a. Open and friendly, ask direct questions, touch the patient's arm or hand occasionally for reassurance. b. Frequent nonverbal behaviors, such as gestures and smiles, make an unemotional face to express negatives. c. Soft voice, break eye contact occasionally, general leads and reflective techniques. d. Stern voice, unbroken eye contact, minimal gestures, direct questions.

C Native American culture stresses living in harmony with nature. Cooperative, sharing styles rather than competitive or intrusive approaches are preferred.

A nurse begins work in an agency that provides care to members of a minority ethnic population. The nurse will be better able to demonstrate cultural competence after a. identifying culture-bound issues. b. implementing scientifically proven interventions. c. correcting inferior health practices of the population. d. exploring commonly held beliefs and values of the population.

D Cultural competence is dependent on understanding the beliefs and values of members of a different culture. A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture. The other options have little to do with cultural competence or represent only a portion of the answer.

Which Western cultural feature may result in establishing unrealistic outcomes for patients of other cultural groups? a. Interdependence b. Present orientation c. Flexible perception of time d. Direct confrontation to solve problems

D Directly confronting problems is a highly valued approach in the American culture but not part of many other cultures in which harmony and restraint are valued

A Native American patient sadly describes a difficult childhood. The patient abused alcohol as a teenager but stopped 10 years ago. The patient now says, "I feel stupid and good for nothing. I don't help my people." How should the treatment team focus planning for this patient? a. Psychopharmacological and somatic therapies should be central techniques. b. Apply a psychoanalytical approach, focused on childhood trauma. c. Depression and alcohol abuse should be treated concurrently. d. Use a holistic approach, including mind, body, and spirit.

D Native Americans, because of their beliefs in the interrelatedness of parts and about being in harmony with nature, respond best to a holistic approach.

A black patient, originally from Haiti, has a diagnosis of major depressive disorder. A colleague tells the nurse, "This patient often looks down and is reluctant to share feelings. However, I've observed the patient spontaneously interacting with other black patients." Select the nurse's best response. a. "Black patients depend on the church for support. Have you consulted the patient's pastor?" b. "Encourage the patient to talk in a group setting. It will be less intimidating than one-to-one interaction." c. "Don't take it personally. Black patients often have a resentful attitude that takes a long time to overcome." d. "The patient may have difficulty communicating in English. Have you considered using a cultural broker?"

D Society expects a culturally diverse patient to accommodate and use English. Feelings are abstract, which requires a greater command of the language. This may be especially difficult during episodes of high stress or mental illness. Cultural brokers can be helpful with language and helping the nurse to understand the Haitian worldview and cultural nuances.

A nurse prepares to assess a newly hospitalized patient who moved to the United States 6 months ago from Somalia. The nurse should first determine a. if the patient's immunizations are current. b. the patient's religious preferences. c. the patient's specific ethnic group. d. whether an interpreter is needed.

D The assessment depends on communication. The nurse should first determine whether an interpreter is needed. The other information can be subsequently assessed.

To provide culturally competent care, the nurse should a. accurately interpret the thinking of individual patients. b. predict how a patient may perceive treatment interventions. c. formulate interventions to reduce the patient's ethnocentrism. d. identify strategies that fit within the cultural context of the patient.

D The correct answer is the most global response.

A white patient of German descent rocks back and forth, grimaces, and rubs both temples. What is the nurse's best action? a. Assess the patient for extrapyramidal symptoms. b. Sit beside the patient and rock in sync. c. Offer to pray with the patient. d. Assess the patient for pain.

D This patient of German descent would hold a Western worldview and be stoic about pain. This patient will keep pain as silent as possible and be reluctant to disclose pain unless the nurse actively assesses for it.

Detoxification protocols have been developed and implemented for all of the following substances, except A. alcohol B. opioids C. cannabinoids D. nicotine

Detoxification protocols have been developed and implemented for all of the following substances, except C. cannabinoids

Which of the following statements most accurately describes the concept of tolerance? A. A person needs increasing amounts of a substance to achieve a desired effect. B. A person develops over time a psychological dependence on a substance. C. A person uses greater amounts of a substance for longer periods than he/she intended. D. A person has frequent periods of unsuccessfully trying to stop using the substance.

Which of the following statements most accurately describes the concept of tolerance? A. A person needs increasing amounts of a substance to achieve a desired effect.

An individual comes to the crisis clinic for a first visit and reports not sleeping well, anxiety, and excessive crying. These symptoms occurred shortly after a sudden job loss and losing his or her home to a tornado that devastated the town in which the patient lives. Which of the following statements regarding crisis accurately describes the individual's situation? a. The patient is experiencing both a situational and an adventitious crisis. b. The patient is experiencing a situational crisis with the added stress of financial burden. c. The patient is experiencing ineffective coping and should be hospitalized for intensive therapy. d. The patient is experiencing low self-esteem from the job loss, as well as anger because of the loss of his or her home.

a

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

a

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

a

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

a

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

a. "I cannot recall why I'm living in this town." The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. See relationship to audience response question.

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

a. "In the past, how have you handled difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the patient to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis.

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

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

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

d

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

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are lost to the patient (blackouts). See relationship to audience response question.

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

a. Difficulty using a cell phone d. Rapid speech e. Trembling Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

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

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

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

a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.

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

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

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

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

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

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

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

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

The nurse is assessing a patient rescued from a terrorist attack and finds that the patient has impaired thinking and severe anxiety. Which strategy does the nurse use while conducting crisis intervention for the patient? Select all that apply. a. The nurse focuses on the present situation of the patient. b. The nurse assists the patient to identify past coping skills. c. The nurse assures the patient that they will be fine within 2 days. d. The nurse encourages the patient to focus on multiple implications at a time. e. The nurse encourages the patient to express feelings in a nondestructive manner.

abe

___ crisis is not a part of daily life. It develops due to events like natural disasters, national disasters like terrorist attacks, and crime.

adventitious

A nurse assesses a patient in crisis. Select the most appropriate question for the nurse to ask to assess this patient's situational support. a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b

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

b

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

b. "Her death is a terrible loss for you." Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

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

b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.

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

b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

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

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

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

b. Adventitious An adventitious crisis is a crisis of disaster that is not a part of everyday life. It is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. "Organic" is not a type of crisis..

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

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

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

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

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

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

The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

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

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

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

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

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

b. anxious and fearful. Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety.

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

d

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

b. ask what other relatives or friends are available for support. The assessment of situational supports should continue. Even though the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually non-therapeutic.

Which outcome indicates the individual is demonstrating a commonly observed but negative coping strategy after a crisis event? Select all that apply. a. Running 5 miles daily b. Gaining 10 pounds over a 6-week period c. Losing one's driver's license for driving drunk d. Offering numerous excuses for not socializing e. Scheduling spiritual counseling sessions three times a week

bcd

A major hurricane destroyed a community. Afterward, which comment best predicts that a victim will be able to maintain or promptly return to a state of equilibrium? a. "I think we will be fine. There are emergency agencies that will take care of us." b. "It seems that trouble always finds me. Like in the past, I will do my best to cope with this disaster." c. "We had had big storms before. If we pull together, we can help each other and rebuild our community." d. "This storm wasn't so bad. It could have killed more people or destroyed the underground power lines."

c

A patient is treated in the emergency department for injuries sustained while vacationing hundreds of miles away from home. To best meet the patient's emotional needs, the nurse should do which of the following? a. Arrange to hospitalize the patient. b. Refer the patient for traditional psychotherapy for post-traumatic stress disorder. c. Provide temporary support by arranging shelter and contacting the patient's friends. d. Suggest that contacting a victim support group would be more appropriate than crisis intervention.

c

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

c. 4 to 8 weeks. The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 8 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

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

c. Anger is an expected emotion in an adjustment disorder. Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

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

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

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

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

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

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

After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

c. hippocampus. The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

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

d

To assess the patient's perception of the event precipitating a crisis, the nurse would initially ask which of the following questions? a. "Who is available to help you?" b. "Can you give me the name of someone you trust?" c. "During difficult times in the past, what has helped you?" d. "What was happening just before you began feeling this way?"

d

What are the two initial goals for crisis interventions? a. Anxiety reduction and coping b. Crisis resolution and planning c. Assessment and nursing diagnosis d. Patient safety and anxiety reduction

d

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

d

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

d. "Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

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

d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

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

d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

A patient being seen in the clinic for superficial cuts on both wrists is pacing and sobbing. After a few minutes, the patient is calmer. The nurse attempts to determine the patient's perception of the precipitating event by asking: a. "Tell me why you were crying." b. "How did your wrists get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started to feel this way?"

d. "What was happening just before you started to feel this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits assessment of the precipitating event. "Why" questions are non-therapeutic.

Which scenario is an example of an adventitious crisis? a. The death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old person d. A riot at a rock concert

d. A riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

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

d. Clarify what the patient means by "I can't take anymore." During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

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

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

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

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.