Final Exam Psych

26. A hospitalized patient with delirium misinterprets reality and a patient with dementia wanders about the home. Which outcome is the priority in both scenarios? Each patient will: a. remain safe in the present environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern in both scenarios. Safety maintenance is the desired outcome. The other outcomes are priorities and may not be realistic.

21. The assumption 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 a high potential for self-injury.

ANS: A 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. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

15. A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you began feeling depressed."

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation.

11. A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. Attention deficit hyperactivity disorder ADHD. b. Childhood depression. c. Conduct disorder CD. d. autism spectrum disorder ASD

ANS: C CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) identifies CDs as: serious violations of rules. The patient's clinical manifestations do not coincide with the other disorders listed.

27. When alprazolam (Xanax) is prescribed for acute anxiety, health teaching should include instructions to: a. Report drowsiness. b. Eat a tyramine-free diet. c. Avoid alcoholic beverages. d. Adjust dose and frequency based on anxiety level.

ANS: C Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.

39. A patient in an alcohol rehabilitation program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance

ANS: A Low self-esteem is present when a patient sees him- or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.

22. Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

14. A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care? a. Anxiety b. Risk for suicide c. Disturbed body image d. Ineffective role performance

ANS: B A high risk of completed suicide exists in patients with body dysmorphic disorder. Safety is always a high priority for the nurse; in this instance, the plan of care should include an awareness of the risk for self-inflicted harm.

22. Which beverage should the nurse offer to a patient with depression who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk

ANS: D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

18. A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. Repression b. Devaluation c. Identification d. Compensation

ANS: D Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.

7. A patient is undergoing diagnostic tests. The patient says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports that the patient smokes, coughs daily, has lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a. Displacement b. Regression c. Projection d. Denial

ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.

12. An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

ANS: D Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

9. A nurse should assess a patient taking a medication with anticholinergic properties for inhibited function of the: a. parasympathetic nervous system b. sympathetic nervous system c. reticular activating system d. medulla oblongata

ANS: A Acetylcholine is the neurotransmitter found in high concentration in the parasympathetic nervous system. When acetylcholine action is inhibited by anticholinergic drugs, parasympathetic symptoms such as blurred vision, dry mouth, constipation, and urinary retention appear. The functions of the sympathetic nervous system, the reticular activating system, and the medulla oblongata are not affected by anticholinergic medications.

18. A patient with schizophrenia is acutely disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position; the lower jaw is thrust forward, and the patient is drooling. Which problem is most likely? a. Acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back; opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies that require immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis; it appears after prolonged treatment. Waxy flexibility is a symptom observed in catatonic schizophrenia. Akathisia is evidenced by internal and external restlessness, pacing, and fidgeting.

17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a. Altruism b. Sublimation c. Suppression d. Passive aggression

ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurse's reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others.

18. A nurse counseling a patient with a dissociative identity disorder should understand that the assessment of highest priority is: a. Risk for self-harm b. Cognitive functioning c. Identification of drug abuse d. Readiness to reestablish identity or memory

ANS: A Assessments that relate to patient safety take priority. Patients with dissociative identity disorders may be at risk for suicide or self-mutilation; therefore the nurse must be alert for hints of hopelessness, helplessness and worthlessness, low self-esteem, and impulses to self-mutilate. The distracters are important assessments but rank beneath safety.

5. A child with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

ANS: A Central nervous system stimulants increase blood flow to the brain and have proven helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

19. Priority teaching for a patient taking clozapine (Clozaril) should include which instruction? a. Report sore throat and fever immediately. b. Avoid foods high in polyunsaturated fat. c. Use water-based lotions for rashes. d. Avoid unprotected sex.

ANS: A Clozapine therapy may produce agranulocytosis; therefore signs of infection should be immediately reported to the health care provider. In addition, the patient should have white blood cell levels measured weekly. The other options are not relevant to clozapine administration.

18. Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered: a. mentally ill. b. intent on dying. c. cognitively impaired. d. experiencing hopelessness.

ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired.

14. Which nursing intervention has the highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

2. A nurse assesses a patient suspected to have complex somatic system disorder. Which findings support the diagnosis? Select all that apply. a. Patient is a woman. b. Patient reports frequent syncope. c. Patient complains of heavy menstrual bleeding. d. Patient was first diagnosed with psoriasis at 12 years of age. e. Patient reports back pain, painful urination, frequent diarrhea, and hemorrhoids.

ANS: A, B, C, E No chronic disease explains the symptoms for patients with complex somatic system disorder. Patients report multiple symptoms; and gastrointestinal, sexual, and pseudoneurological symptoms are common. This disorder is more common is women than in men.

1. The family members of a patient newly diagnosed with paranoid schizophrenia state that they do not understand what has caused the illness. The nurse's response should be based on which models? Select all that apply. a. Neurobiological b. Developmental c. Family theory d. Genetic e. Stress

ANS: A, D Compelling evidence exists that schizophrenia is a neurologic disorder probably related to neurochemical abnormalities, neuroanatomical disruption of brain circuits, and genetic vulnerability. Stress, family disruption, and developmental influences may contribute but are not considered single etiologic factors.

1. 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 be expected 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

ANS: A, D, E 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.

4. A patient has delusions and hallucinations. Before beginning treatment with a psychotropic medication, the health care provider wants to rule out the presence of a brain tumor. For which test will a nurse need to prepare the patient? a. Cerebral arteriogram b. Computed tomography (CT) scan or magnetic resonance imaging (MRI) c. Positron emission tomography (PET) or single photon emission computed tomography (SPECT) d. Functional magnetic resonance imaging (fMRI)

ANS: B A CT scan and an MRI visualize neoplasms and other structural abnormalities. A PET scan, SPECT scan, and fMRI, which give information about brain function, are not indicated. An arteriogram would not be appropriate.

25. Which nursing diagnosis would likely apply to both patients with paranoid schizophrenia and patients with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane

ANS: B Both types of patients commonly experience paranoid delusions; thus the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Aloofness, haughtiness, suspicion b. Darting eyes, tilted head, mumbling to self c. Elevated mood, hyperactivity, distractibility d. Performing rituals, avoiding open places

ANS: B Clues to hallucinations include looking around the room as though to find the speaker; tilting the head to one side as though intently listening; and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

18. During morning care, a nursing assistant asks a patient with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation is the making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

2. A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia b. idea of reference c. delusion of infidelity d. auditory hallucination

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

15. When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

ANS: B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

19. Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I shot myself."

ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide.

16. A patient experiences an episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to administer as an as-needed (prn) anxiolytic medication? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

ANS: B Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

13. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

27. A patient with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse expects a change to which medication? a. haloperidol (Haldol) b. olanzapine (Zyprexa) c. chlorpromazine (Thorazine) d. diphenhydramine (Benadryl)

ANS: B Olanzapine is an atypical antipsychotic medication that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotic agents that target only positive symptoms. Diphenhydramine is an antihistamine.

22. An appropriate question for the nurse to ask to assess situational support is: 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?"

ANS: B Only the correct answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

20. A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results are normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Functional neurologic (conversion) disorder b. Prominent health anxiety (hypochondriasis) c. Predominant (pain) disorder d. Dissociative fugue

ANS: B Patients with hypochondriasis have fears of serious medical problems such as cancer or heart disease. These fears persist, despite medical evaluations, and interfere with daily functioning. No complaints of pain are made, and no evidence of dissociation or conversion exists.

1. A medical-surgical nurse works with a patient diagnosed with a somatic system disorder. Care planning is facilitated by understanding that the patient will probably: a. Readily seek psychiatric counseling. b. Be resistant to accepting psychiatric help. c. Attend psychotherapy sessions without encouragement. d. Be eager to discover the true reasons for physical symptoms.

ANS: B Patients with somatic system disorders go from physician to physician trying to establish a physical cause for their symptoms. When a psychologic basis is suggested and a referral for counseling is offered, these patients reject both.

9. A patient with catatonic schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Psychosocial b. Physiologic c. Self-actualization d. Safety and security

ANS: B Physiologic needs must be met to preserve life. A patient who is semistuporous must be fed by hand or tube, toileted, and given range-of-motion exercises to preserve physiologic integrity. Safety needs rank second to physical needs. Higher level needs are of lesser concern.

19. A patient with Alzheimer's disease wanders at night. Which action should the nurse recommend for a family to use in the home to enhance safety? a. Place throw rugs on tile or wooden floors. b. Place locks at the tops of doors. c. Encourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the patient with dementia to unlock the door because the ability to look up and reach upward is diminished. All throw rugs should be removed to prevent falls. The patient will try to climb over side rails, increasing the risk for injury and falls. Day napping should be discouraged with the hope that the patient will sleep during the night.

32. A patient with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tells you to do frighten you?" c. "Do you recognize the voice speaking to you?" d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the patient to do is important; the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

9. A patient who is preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Describe the procedure again in a calm manner using simple language. c. Tell the patient that the staff is prepared to promote recovery. d. Encourage the patient to express feelings to his or her family.

ANS: B Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the remaining options will further scatter the patient's attention.

23. The acronym QSEN refers to: a. Qualitative Standardized Excellence in Nursing. b. Quality and Safety Education for Nurses. c. Quantitative Effectiveness in Nursing. d. Quick Standards Essential for Nurses.

ANS: B QSEN represents national initiatives centered on patient safety and quality. The primary goal of QSEN is to prepare future nurses with the knowledge, skills, and attitudes to increase the quality, care, and safety in the health care setting in which they work.

24. A patient says, "I know I have a brain tumor despite the results of the magnetic resonance image (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive restructuring? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your illogical thinking." b. "Let's see whether any other explanations for your vomiting are possible." c. "You seem so worried. Let's talk about how you're feeling." d. "We'll talk about something else."

ANS: B Questioning the evidence is a cognitive restructuring technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective.

23. A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Strategically place large clocks and calendars.

ANS: B Reorientation may seem like arguing to a patient with cognitive deficits and increases the patient's anxiety. Validating, talking with the patient about familiar, meaningful things, and reminiscing give meaning to existence both for the patient and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and strategically placing large clocks and calendars are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable; patients with dementia sometimes become more agitated with reorientation.

1. Which changes in brain biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises.

21. Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the norm.

12. A patient with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy, and priority information is given to the patient and family. This information should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.

ANS: B Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

1. A patient asks a nurse, "What are neurotransmitters? My doctor says mine are out of balance." The best reply would be: a. "You must feel relieved to know that your problem has a physical basis." b. "Neurotransmitters are chemicals that pass messages between brain cells." c. "It is a high-level concept to explain. You should ask the doctor to tell you more." d. "Neurotransmitters are substances we eat daily that influence memory and mood."

ANS: B Stating that neurotransmitters are chemicals that pass messages between brain cells gives the most accurate information. Neurotransmitters are messengers in the central nervous system. They are released from the axon terminal, diffuse across the synapse, and attach to specialized receptors on the postsynaptic neuron. The incorrect responses do not answer the patient's question, are demeaning, and provide untrue and misleading information.

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

ANS: B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

37. Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in 1 year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, "I see the need for ongoing treatment." c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: B The answer refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not provide enough information to know whether anger has been identified as a problem. A trusting relationship, although desirable, would not help the patient maintain sobriety.

2. A child with attention deficit hyperactivity disorder (ADHD) has hyperactivity, distractibility, and impaired play. The health care provider prescribed methylphenidate (Concerta). The desired behavior for which the nurse should monitor is: a. increased expressiveness in communicating with others b. improved ability to participate in play with other children c. ability to identify anxiety and implement self-control strategies d. improved socialization skills with other children and authority figures

ANS: B The goal is improvement in the child's hyperactivity, distractibility, and play. The remaining options are more relevant for a child with a pervasive developmental or anxiety disorder.

7. An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be: a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the patient's access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical.

13. Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

ANS: B 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.

7. Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

3. A patient has blindness related to a functional neurological (conversion) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed him- or herself after explaining the arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self unassisted. d. address the needs of other patients in the dining room, and then feed this patient.

ANS: B The patient is expected to maintain some level of independence by feeding him- or herself, whereas the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support.

20. An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

ANS: B The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

23. A child blurts out answers to questions before the questions are complete, demonstrates an inability to take turns, and persistently interrupts and intrudes in the conversations of others. Assessment data show these behaviors relate primarily to: a. hyperactivity b. impulsivity c. inattention d. defiance

ANS: B These behaviors demonstrate impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is a failure to listen. Defiance is willfully doing what an authority figure has said not to do.

21. A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the student's experience as: a. Culturally influenced b. Displacement c. Trait anxiety d. Mild anxiety

ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms.

11. A patient admitted to an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening." Which defense mechanism is evident? a. Rationalization b. Introjection c. Projection d. Denial

ANS: D Minimizing one's drinking is a form of denial of alcoholism. The patient's own description indicates that "social drinking" is not an accurate name for the behavior. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjection involves taking a quality into one's own system.

4. A patient is very suspicious and states, "The FBI has me under surveillance." Which strategies should a nurse use when gathering initial assessment data about this patient? Select all that apply. a. Tell the patient that medication will help this type of thinking. b. Ask the patient, "Tell me about the problem as you see it." c. Seek information about when the problem began. d. Tell the patient, "Your ideas are not realistic." e. Reassure the patient, "You are safe here."

ANS: B, C, E During the assessment interview, the nurse should listen attentively and accept the patient's statements in a nonjudgmental way. Because the patient is suspicious and fearful, reassuring safety may be helpful, although trust is unlikely so early in the relationship. Saying that medication will help or telling the patient that the ideas are not realistic will undermine the development of trust between the nurse and patient.

4. After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

ANS: B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. "Reported" should be used instead of "alleged." "Penetration" should be used instead of "intercourse." "Declined" should be used instead of "refused."

1. A nurse assesses a patient who reluctantly participates in activities, answers questions with minimal responses, and rarely makes eye contact. What information should be included when documenting the assessment? Select all that apply. a. Uncooperative patient b. Patient's subjective responses c. Only data obtained from the patient's verbal responses d. Description of the patient's behavior during the interview e. Analysis of why the patient is unresponsive during the interview

ANS: B, D Both the content and process of the interview should be documented. Providing only the patient's verbal responses creates a skewed picture of the patient. Writing that the patient is uncooperative is subjectively worded. An objective description of patient behavior is preferable. Analysis of the reasons for the patient's behavior is speculation, which is inappropriate.

3. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)

ANS: D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids; because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.

26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

ANS: D Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness.

12. A patient has anxiety, increased heart rate, and fear. The nurse would suspect the presence of a high concentration of which neurotransmitter? a. GABA b. Histamine c. Acetylcholine d. Norepinephrine

ANS: D Norepinephrine is the neurotransmitter associated with sympathetic nervous system stimulation, preparing the individual for "fight or flight" response. GABA is a mediator of anxiety level. A high concentration of histamine is associated with an inflammatory response. A high concentration of acetylcholine is associated with parasympathetic nervous system stimulation.

11. A nurse worked with a patient with major depression who displayed severely withdrawn behavior and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

ANS: D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become overinvolved with patients with depression because of the patient's resistance. Guilt and despair might be observed when the nurse experiences patient feelings because of empathy. Interest is possible but not the most likely result.

22. Select the most appropriate label to complete this nursing diagnosis: ___________, related to feelings of shyness and poorly developed social skills as evidenced by watching television alone at home every evening. a. Deficient knowledge b. Ineffective coping c. Powerlessness d. Social isolation

ANS: D Nursing diagnoses are selected on the basis of the etiologic factors and assessment findings or evidence. In this instance, the evidence shows social isolation that is caused by shyness and poorly developed social skills.

10. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Memory impairment

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. No evidence of memory loss is revealed in this scenario.

31. For a patient experiencing panic, which nursing intervention should be first? a. Teach relaxation techniques. b. Administer an anxiolytic medication. c. Provide calm, brief, directive communication. d. Gather a show of force in preparation for gaining physical control.

ANS: C Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.

26. Which behavior indicates that the treatment plan for a child with autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

ANS: C Holding the hand of another person suggests relatedness. Usually, a child with autism would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotypical pattern. The other options reflect behaviors that are consistent with autistic disorder.

9. A nurse administers medications to four patients with Alzheimer's disease. Which medication would be expected to antagonize N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. donepezil (Aricept) b. rivastigmine (Exelon) c. memantine (Namenda) d. galantamine (Razadyne)

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterase inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

33. A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. Acrophobia b. Agoraphobia c. Social phobia d. Posttraumatic stress disorder

ANS: C The fear of a potentially embarrassing situation represents a social phobia. Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Posttraumatic stress disorder is associated with a major traumatic event.

8. A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action? a. Remain silent. b. Educate the patient that the outcome is not realistic. c. Explore with the patient possible consequences of the outcome. d. Formulate an appropriate outcome without the patient's input.

ANS: C The nurse should not impose outcomes on the patient; however, the nurse has a responsibility to help the patient evaluate what is in his or her best interest. Exploring possible consequences is an acceptable approach.

19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.

ANS: C The symptoms given in the question are consistent with narcotic withdrawal. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.

27. Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache

ANS: C The symptoms of withdrawal from various CNS depressants are similar. Generalized seizures are possible.

4. A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options.

14. A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

3. What information is conveyed by nursing diagnoses? Select all that apply. a. Medical judgments about the disorder b. Goals and outcomes for the plan of care c. Unmet patient needs currently present d. Supporting data that validate the diagnoses e. Probable causes that will be targets for nursing interventions

ANS: C, D, E Nursing diagnoses focus on phenomena of concern to nurses rather than on medical diagnoses.

4. A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply. a. Schizophrenia b. Eating disorder c. Traumatic brain injury d. Seasonal affective disorder e. Posttraumatic stress disorder

ANS: C, E Traumatic brain injury and posttraumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distracters would be expected to parallel the general population.

31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway

ANS: D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.

11. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

16. Which child shows behaviors indicative of mental illness? a. 4-year-old who stuttered for 3 weeks after the birth of a sibling b. 9-month-old who does not eat vegetables and likes to be rocked c. 3-month-old who cries after feeding until burped and sucks a thumb d. 3-year-old who is mute, passive toward adults, and twirls while walking

ANS: D Symptoms consistent with an autistic spectrum disorder (ASD) are evident in the correct answer. The behaviors of the other children are within normal ranges.

16. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are most important and which are less important."

ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

24. Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

17. Which scenario is an example of an adventitious crisis? a. 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 d. Riot at a rock concert

ANS: D 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.

11. Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to get help." c. "We need to talk about the good things you have to live for." d. "Bringing this up is a very positive action on your part."

ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem-solving strategies.

20. A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. I can't take care of my baby. This baby is the root of my problems." The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence

ANS: D When the mother with depression of postpartum onset has ruminations or delusional thoughts about the infant, the risk for harming the infant is increased; thus it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.

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

ANS: A AA is a peer support group for recovering alcoholics. The goal is to maintain sobriety. Neither professional nor peer leaders are appointed.

20. Physical assessment of a patient with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

21. A nurse caring for a patient taking a serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to: a. mood improvement b. logical thought processes c. reduced levels of motor activity d. decreased extrapyramidal symptoms

ANS: A SSRIs affect mood, relieving depression in many patients. SSRIs do not act to reduce thought disorders. SSRIs reduce depression but have little effect on motor hyperactivity. SSRIs do not produce extrapyramidal symptoms.

12. Consider these problems: apolipoprotein E (apoE) malfunction, neuritic plaques, neurofibrillary tangles, granulovascular degeneration, and brain atrophy. Which condition corresponds to this group? a. Alzheimer's disease b. Acquired immunodeficiency syndrome (AIDS)-related dementia c. Wernicke's encephalopathy d. Central anticholinergic syndrome

ANS: A The problems are all aspects of the pathophysiologic characteristics of Alzheimer's disease.

2. Which assessment findings would the nurse expect in a patient with delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place and time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Patients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

15. A patient hospitalized with a mood disorder has aggression, agitation, talkativeness, and irritability. A nurse begins the care plan based on the expectation that the health care provider is most likely to prescribe a medication classified as a(n): a. anticholinergic b. mood stabilizer c. psychostimulant d. antidepressant

ANS: B The symptoms describe a manic attack. Mania is effectively treated by the antimanic drug lithium and selected anticonvulsants such as carbamazepine, valproic acid, and lamotrigine. No drugs from the other classifications listed are effective in the treatment of mania.

17. A patient with schizophrenia has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. The nurse now assesses a shuffling propulsive gait, a masklike face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson disease. It frequently appears within the first month of treatment. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

11. Which assessment question would be most appropriate to ask a patient who has possible generalized anxiety disorder? a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Do you feel especially uncomfortable in social situations involving people?" c. "Do you repeatedly do certain things over and over again?" d. "Do you find it difficult to control your worrying?"

ANS: D Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

25. After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as: a. not at all satisfied b. somewhat satisfied c. moderately satisfied d. very satisfied

ANS: D The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychologic care. No indicators express low-to-moderate satisfaction.

12. Which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care? a. "I can always trust my family." b. "It seems like I always have bad luck." c. "You never know who will turn against you." d. "I hear evil voices that tell me to do bad things."

ANS: D The statement regarding evil voices tells the nurse that the patient is experiencing auditory hallucinations. The other statements are vague and do not clearly identify the patient's chief symptom.

23. An essential difference between somatic system disorders and dissociative disorders is: a. Somatic system disorders are under voluntary control, whereas dissociative disorders are unconscious and automatic. b. Dissociative disorders are precipitated by psychologic factors, whereas somatic system disorders are related to stress. c. Dissociative disorders are individually determined and related to childhood sexual abuse, whereas somatic system disorders are culture bound. d. Dissociative disorders entail stress-related disruptions of memory, consciousness, or identity, whereas somatic system disorders involve the expression of psychologic stress through somatic symptoms.

ANS: D The key is the only fully accurate statement. Somatic system disorders are not under voluntary control and are not culture bound.

7. Shortly after a 15-year-old's parents announce a plan to divorce, the adolescent stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "All the other kids have families. If my parents loved me, then they would stay together." Which nursing intervention is most appropriate? a. Develop a plan for activities of daily living. b. Communicate disbelief relative to the adolescent's feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescent's level of depression daily.

ANS: C The patient's perceptions that all the other kids are from two-parent households and that he or she is different are not based in reality. Assisting the patient to test the accuracy of the perceptions is helpful.

16. A patient's employment is terminated and major depression results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

ANS: C The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to lead to other diagnoses.

13. A person has minor physical injuries after an automobile accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is this person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in a panic level of anxiety demonstrates significantly disturbed behavior and may lose touch with reality.

2. In which situations does a nurse have a duty to intervene and report? Select all that apply. a. A peer is unable to write behavioral outcomes. b. A health care provider consults the Physicians' Desk Reference. c. A peer tries to provide patient care in an alcohol-impaired state. d. A team member has violated the boundaries of a vulnerable patient. e. A patient refuses a medication prescribed by a licensed health care provider.

ANS: C, D Both instances jeopardize patient safety. The nurse must practice within the Code of Ethics for Nurses. A peer being unable to write behavioral outcomes is a concern but can be informally resolved. A health care provider consulting the Physicians' Desk Reference is acceptable practice.

2. A nurse prepares the plan of care for a 15-year-old adolescent with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will: select all that apply. a. Live unaided in an apartment. b. Complete high school or earn a general equivalency diploma (GED). c. Independently perform his or her own personal hygiene. d. Obtain employment in a local sheltered workshop. e. Correctly use public buses to travel in the community.

ANS: C, D, E Individuals with moderate intellectual developmental disorder progress academically to about a second grade level. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, they can function in the community, but independent living is not likely.

1. A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) (DSM-IV-TR) b. State's nurse practice act c. State and federal regulations that govern hospitals d. Summary of common practices of several local hospitals e. American Nurses Association Scope and Standards of Practice for Psychiatric-Mental Health Nursing Practice

ANS: C, E Regulations regarding hospitals provide information about the minimal standard. The American Nurses Association (ANA) national standards focus on elevating practice by setting high standards for nursing practice. The DSM-IV-TR and the state's nurse practice act would not provide relevant information. A summary of common practices of several local hospitals cannot be guaranteed to be helpful because the customs may or may not comply with laws or best practices.

2. A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started to feel this way?"

ANS: D A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking "why" questions is a poor communication technique.

26. When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

ANS: D A matter-of-fact statement that the nurse's perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

6. A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day when asked about the project, the worker says, "I've been working on other things." When asked 4 hours later, the worker says, "Someone else was using the copier, so I couldn't finish it." The worker's behavior demonstrates: a. acting out. b. projection. c. rationalization. d. passive aggression.

ANS: D A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks.

6. Which environmental adjustment should the nurse make for a patient with delirium and perceptual alterations? a. Keep the patient by the nurse's desk while the patient is awake. Provide rest periods in a room with a television on. b. Light the room brightly day and night. Awaken the patient hourly to assess mental status. c. Maintain soft lighting day and night. Keep a radio on low volume continuously. d. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

ANS: D A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

9. The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

13. A patient has symptoms of acute anxiety related to the death of a parent in an automobile accident 2 hours earlier. The nurse should prepare to teach the patient about a medication from which group? a. Tricyclic antidepressants b. Atypical antipsychotics c. Anticonvulsants d. Benzodiazepines

ANS: D Benzodiazepines provide anxiety relief. Tricyclic antidepressants are used to treat symptoms of depression. Anticonvulsants are used to treat bipolar disorder or seizures. Antipsychotic drugs are used to treat psychosis.

19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. Maintaining patients' concentration and attention. b. Shifting the patients' focus from food to psychotherapy. c. Focusing on weight control mechanisms and food preparation. d. Processing the heightened anxiety levels associated with eating.

ANS: D Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced b. dependent on alcohol c. healthy but underweight d. microcephalic and cognitively impaired

ANS: D Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distracters.

12. A 15-year-old adolescent is referred to a residential program after an arrest for theft and running away from home. At the program, the adolescent refuses to participate in scheduled activities and pushes a staff member, causing a fall. Which approach by the nursing staff would be most therapeutic? a. Neutrally permit refusals b. Coax to gain compliance c. Offer rewards in advance d. Establish firm limits

ANS: D Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teenager's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure.

34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia b. hypothermia c. hallucinations d. anterograde amnesia

ANS: D Flunitrazepam is also known as the date rape drug; it produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.

18. A nurse can anticipate anticholinergic side effects will be likely when a patient is taking: a. lithium (Lithobid) b. buspirone (BuSpar) c. risperidone (Risperdal) d. fluphenazine (Prolixin)

ANS: D Fluphenazine, a first-generation antipsychotic medication, exerts muscarinic blockade, resulting in dry mouth, blurred vision, constipation, and urinary retention. Lithium therapy is more often associated with fluid balance problems, including polydipsia, polyuria, and edema. Risperidone therapy is more often associated with movement disorders, orthostatic hypotension, and sedation. Buspirone is associated with anxiety reduction without major side effects.

22. Which individual in the emergency department should be considered at the highest risk for completing suicide? a. An adolescent Asian-American girl with superior athletic and academic skills who has asthma b. A 38-year-old single African-American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single white man with cancer of the prostate gland

ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."

ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment.

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. Weigh self accurately using balanced scales. b. Limit exercise to less than 2 hours daily. c. Select clothing that fits properly. d. Gain 1 to 2 pounds.

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

20. A nurse cares for patients taking various medications, including buspirone (BuSpar), haloperidol (Haldol), trazodone (Desyrel), and phenelzine (Nardil). The nurse will order a special diet for the patient taking: a. buspirone b. haloperidol c. trazodone d. phenelzine

ANS: D Patients taking phenelzine, an MAOI, must be on a tyramine-free diet to prevent hypertensive crisis.

9. A patient states, "I'm not worth anything. I have negative thoughts about myself. I feel anxious and shaky all the time. Sometimes I feel so sad that I want to go to sleep and never wake up." Which nursing intervention should have the highest priority? a. Self-esteem-building activities b. Anxiety self-control measures c. Sleep enhancement activities d. Suicide precautions

ANS: D The nurse should place priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem while giving priority attention to suicide self-restraint.

25. A patient diagnosed with paranoid schizophrenia angrily tells a nurse, "You act like a homosexual. No one trusts you or wants to be around you." Select the most likely analysis. The patient: a. is showing reaction formation in response to feelings of abandonment. b. is unleashing unconscious, hostile feelings toward the nurse. c. is dwelling on others' shortcomings, thus placing them on the defensive. d. may be projecting homosexual urges.

ANS: D Patients with paranoid ideation unconsciously use the defense mechanism projection to deal with unacceptable, anxiety-producing ideas and impulses, in this case homosexual urges. Although the behavior seems hostile, the projection is homosexual urges rather than hostility. Patients who exhibit paranoid ideation usually fear abandonment, but this situation does not represent reaction formation to abandonment feelings. Although it is true that dwelling on others' shortcomings places them on the defensive, it is not the correct analysis of the behavior described in the scenario.

17. The child most likely to receive propranolol (Inderal) to control aggression, deliberate self-injury, and temper tantrums is one diagnosed with: a. Attention deficit hyperactivity disorder ADHD. b. Posttraumatic stress disorder. c. Separation anxiety. d. Autistic disorder ASD.

ANS: D Propranolol is useful for controlling aggression, deliberate self-injury, and temper tantrums of some autistic children. It is not indicated in any of the other disorders.

24. Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities have goals of complete change in lifestyle, abstinence from drugs, elimination of criminal behaviors, development of employable skills, self-reliance, and honesty. Residential programs are more effective than outpatient programs for patients with antisocial tendencies.

1. An older adult patient takes digoxin and hydrochlorothiazide daily, as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium b. dementia c. amnestic syndrome d. Alzheimer's disease

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

19. Which documentation indicates the treatment plan of a patient with major depression was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

ANS: A Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.

3. A nurse should anticipate that which symptoms of Alzheimer's disease will become apparent as the disease progresses from moderate to severe to late stage? Select all that apply. a. Agraphia b. Hyperorality c. Fine motor tremors d. Hypermetamorphosis e. Improvement of memory

ANS: A, B, D The memories of patients with Alzheimer's disease continue to deteriorate. These patients demonstrate the inability to read or write (agraphia), the need to put everything into the mouth (hyperorality), and the need to touch everything (hypermetamorphosis). Fine motor tremors are associated with alcohol withdrawal delirium, not dementia.

1. When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

3. Which assessment questions are most appropriate to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a. "Have you been a victim of a crime or seen someone badly injured or killed?" b. "Are there certain social situations that cause you to feel especially uncomfortable?" c. "Do you have to do things in a certain way to feel comfortable?" d. "Is it difficult to keep certain thoughts out of awareness?" e. "Do you do certain things over and over again?"

ANS: C, D, E The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia.

8. A patient has disorganized thinking associated with schizophrenia. Neuroimaging would most likely show dysfunction in which part of the brain? a. Brainstem b. Cerebellum c. Temporal lobe d. Prefrontal cortex

ANS: D The prefrontal cortex is responsible for intellectual functioning. The temporal lobe is responsible for the sensation of hearing. The cerebellum regulates skeletal muscle coordination and equilibrium. The brainstem regulates internal organs.

1. A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "The staff here cares about you and wants to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

ANS: D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point.

5. A person attempts suicide by overdose, is treated in the emergency department, and is then hospitalized. What is the best initial outcome? The patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

22. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

30. A patient with schizophrenia begins to talks about "volmers" hiding in the warehouse at work. The term "volmers" should be documented as: a. neologism b. concrete thinking c. thought insertion d. idea of reference

ANS: A A neologism is a newly coined word having special meaning to the patient. "Volmer" is not a known common noun. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others that are implanted in one's mind. An idea of reference is a type of delusion in which trivial events are given personal significance.

13. Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Suicide may be precipitated by a variety of internal and external events. c. Suicidal patients have difficulty using social supports. d. Suicide is an impulsive act.

ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

17. A patient with depression does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective action. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require "yes" or "no" answers. d. Frequently reassure the patient to reduce guilt feelings.

ANS: A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.

22. The causes of somatic system disorders may be related to: a. faulty perceptions of body sensations. b. traumatic childhood events. c. culture-bound phenomena. d. depressive equivalents.

ANS: A Structural or functional abnormalities of the brain have been suggested to lead to the somatic system disorders, resulting in disturbed processes of perception and interpretation of bodily sensations. Furthermore, cognitive theorists believe patients misinterpret the meaning of certain bodily sensations and then become excessively alarmed by them. Traumatic childhood events are related to the dissociative disorders. Culture-bound phenomena may explain the prevalence of some symptoms but cannot explain the cause. Somatic system disorders are not another facet of depression; however, depression may coexist with a somatic system disorder.

15. When working with a patient beginning treatment for alcohol dependence, what is the nurse's most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant

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.

22. A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nursing intervention most suitable for assisting the student is to: a. Explain that the symptoms are the result of mild anxiety, and discuss the helpful aspects. b. Advise the student to discuss this experience with a health care provider. c. Encourage the student to begin antioxidant vitamin supplements. d. Listen without comment.

ANS: A Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

13. A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

ANS: A The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

20. Goals and outcomes for an older adult patient with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function b. identifying stressors negatively affecting self c. demonstrating motor responses to noxious stimuli d. exerting control over responses to perceptual distortions

ANS: A The desired overall goal is that the patient with delirium will return to the level of functioning held before the development of delirium. Demonstrating motor responses to noxious stimuli is an appropriate indicator for a patient whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a patient with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for the patient with sensorium problems related to delirium.

21. A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

ANS: A The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

1. A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

ANS: A The psychologic trauma associated with rape is produced by a number of factors. Of the options given, the threat to life is by far the most traumatic aspect of the crisis. The other options may, however, add significantly to the trauma.

27. A new nurse says to a peer, "My newest patient has schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful? a. "Let's reconsider your plan. Suicide risk is high in patients with schizophrenia." b. "Suicide is a risk for any patient with schizophrenia who uses alcohol or drugs." c. "Patients with schizophrenia are usually too disorganized to attempt suicide." d. "Visual hallucinations often prompt suicide among patients with schizophrenia."

ANS: A Up to 10% of patients with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients with schizophrenia. Patients with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia.

3. Which situations qualify as abandonment on the part of a nurse? (Select all that apply.) The nurse: a. allows a patient with acute mania to refuse hospitalization without taking further action. b. terminates employment without referring a seriously mentally ill for aftercare. c. calls police to bring a suicidal patient to the hospital after a suicide attempt. d. refers a patient with persistent paranoid schizophrenia to community treatment. e. asks another nurse to provide a patient's care because of concerns about countertransference.

ANS: A, B Abandonment arises when a nurse does not place a patient safely in the hands of another health professional before discontinuing treatment. Calling the police to bring a suicidal patient to the hospital after a suicide attempt and referring a patient with schizophrenia to community treatment both provide for patient safety. Asking another nurse to provide a patient's care because of concerns about countertransference demonstrates self-awareness.

2. A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient's privacy may be compromised by the presence of family. The rape victim's anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

2. A nurse plans health teaching for a patient with generalized anxiety disorder who takes lorazepam (Ativan). What information should be included? Select all that apply. a. Use caution when operating machinery. b. Allowed tyramine-free foods in diet. c. Understand the importance of caffeine restriction. d. Avoid alcohol and other sedatives. e. Take the medication on an empty stomach.

ANS: A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.

24. A staff nurse tells another nurse "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse. a. "That action would seem appropriate." b. "A score over 8 requires immediate hospitalization." c. "I think you should strongly consider hospitalization for this patient." d. "Give the patient a follow-up appointment. Hospitalization may be needed soon."

ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization.

21. A patient with depression repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

ANS: B A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

9. When assessing a 2-year-old toddler with suspected autistic disorder, a nurse expects: a. hyperactivity and attention deficits. b. failure to develop interpersonal skills. c. history of disobedience and destructive acts. d. high levels of anxiety when separated from a parent.

ANS: B Autistic disorder involves distortions in the development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers frequently mention the child's failure to develop interpersonal skills. The distracters are more relevant to ADHD, separation anxiety, and CD.

10. A patient with depression tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being exceptionally hard on yourself when you imply you are a jinx." d. "What about the good things that happen; are any of them ever your fault?"

ANS: B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.

12. A college student observes a roommate going out wearing uncharacteristically seductive clothing, returning 12 to 24 hours later and sleeping for 8 to 12 hours. At other times, the roommate sits on the floor speaking like a young child. Which health problem should be considered? a. Functional neurological (conversion) disorder b. Dissociative identity disorder c. Depersonalization disorder d. Body dysmorphic disorder

ANS: B Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. At least two of the subpersonalities take control of the person's behavior but leave the individual unable to remember the periods of time in which the subpersonality is in control.

13. During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, "After discharge, I'm sure everything will be just fine." Which remark by the nurse will be most helpful to the spouse? a. "It is good that you're supportive of your spouse's sobriety and want to help maintain it." b. "Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol." c. "It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection." d. "Remember that alcoholism is a disease of self-destruction. You will need to observe your spouse's behavior carefully."

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

14. A patient is hospitalized for major depression. Of the medications listed, a nurse can expect to provide the patient with teaching about: a. chlordiazepoxide (Librium) b. fluoxetine (Prozac) c. clozapine (Clozaril) d. tacrine (Cognex)

ANS: B Fluoxetine is a selective serotonin reuptake inhibitor (SSRI), an antidepressant that blocks the reuptake of serotonin with few anticholinergic and sedating side effects; clozapine (Clozaril) is an antipsychotic medication; chlordiazepoxide (Librium) is an anxiolytic drug; and tacrine (Cognex) is used to treat Alzheimer disease.

3. 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.

ANS: B Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed.

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

ANS: B Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

13. A patient with stage 1 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Risk for injury b. Impaired memory c. Self-care deficit d. Caregiver role strain

ANS: B Memory impairment is present and expected in stage 1 Alzheimer's disease. Data are not present to suggest the other diagnoses.

8. A patient with a mass in the left upper lobe of the lung is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include a tremulous voice, respirations at 28 breaths per minute, and a pulse rate at 110 beats per minute. What is the patient's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

10. A patient with catatonic schizophrenia is semistuporous, demonstrates little spontaneous movement, and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome is that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing the patient's ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by the nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities; they are difficult to measure and are unrelated to maintaining nutrition.

25. Which treatment modality should a nurse recommend to help a patient with pain disorder cope more effectively? a. Flooding b. Relaxation c. Response prevention d. Systematic desensitization

ANS: B Pain increases when the patient has muscle tension. Relaxation can diminish the patient's perceptions of the intensity of pain. The distracters are modalities useful in treating selected anxiety disorders.

1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "No, that is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

2. A patient approaches the nurse and impatiently blurts out, "You've got to help me! Something terrible is happening. My heart is pounding." The nurse responds, "It's almost time for visiting hours. Let's get your hair combed." Which approach has the nurse used? a. Distracting technique to lower anxiety b. Bringing up an irrelevant topic c. Responding to physical needs d. Addressing false cognitions

ANS: B The nurse has closed off patient-centered communication. The introduction of an irrelevant topic makes the nurse feel better. The nurse is uncomfortable dealing with the patient's severe anxiety.

22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as the medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.

ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers and seeks access to medications. Usually, the person's appearance will deteriorate, and he or she will blame errors on others.

21. After formulating the nursing diagnoses for a new patient, what is the next action a nurse should take? a. Design interventions to include in the plan of care. b. Determine the goals and outcome criteria. c. Implement the nursing plan of care. d. Complete the spiritual assessment.

ANS: B The third step of the nursing process is planning and outcome identification. Outcomes cannot be determined until the nursing assessment is complete and the nursing diagnoses have been formulated.

11. A nurse observes a patient who is in a catatonic state and standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

8. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

ANS: C A reflective communication technique is helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim's perceived role and interfere with further discussion.

8. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

28. A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance intoxication c. Substance dependence d. Recreational use of a social drug

ANS: C Nicotine meets the criteria for a substance, the criterion for dependence (tolerance) is present, and withdrawal symptoms are noted with abstinence or a reduction of the dose. The scenario does not meet the criteria for substance abuse, intoxication, or recreational use of a social drug.

23. If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. "I don't know why it happens." b. "I have poor impulse control." c. "That person shouldn't have provoked me." d. "I'm really a coward who is afraid of being hurt."

ANS: C Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person.

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

ANS: C The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

3. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed.

9. A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not kill or harm myself in any way." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, "I am not going to harm myself, I am going to kill myself," or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

5. A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion

ANS: A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

20. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is: a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

8. Consider these health problems: Lewy body disease, Pick's disease, and Korsakoff's syndrome. Which term unifies these problems? a. Intoxication b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

8. When group therapy is to be used as a treatment modality, the nurse should suggest placing a 9-year-old in a group that uses: a. play activities exclusively. b. group discussion exclusively. c. talk focused on a specific issue. d. play and talk about the play activity.

ANS: D Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

3. A patient has dementia. The health care provider wants to make a differential diagnosis between Alzheimer disease and multiple infarctions. Which diagnostic procedure should a nurse expect to prepare the patient for first? a. Computed tomography (CT) scan b. Positron emission tomography (PET) scan c. Functional magnetic resonance imaging (fMRI) d. Single-photon-emission computed tomography (SPECT) scan

ANS: A A CT scan shows the presence or absence of structural changes, including cortical atrophy, ventricular enlargement, and areas of infarction—information that will be helpful to the health care provider. The other tests focus on brain activity and are more expensive; they may be ordered later.

28. A nurse instructs a patient taking a drug that inhibits the action of a monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

ANS: B Patients taking MAOI-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure.

35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is ordered." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.

ANS: C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.

9. A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

1. A 5-year-old child moves and talks constantly, is easily distracted, and does not listen to the parents. The child awakens before the parents every morning. The child attended kindergarten, but the teacher could not handle the behavior. What is this child's most likely problem? a. Mental retardation b. Oppositional defiant disorder (ODD) c. Pervasive developmental disorder d. Attention deficit hyperactivity disorder (ADHD)

ANS: D The excessive motion, distractibility, and excessive talkativeness suggest ADHD. Developmental delays would be observed if either a pervasive developmental disorder or mental retardation were present. ODD includes serious violations of the rights of others.

19. At what point in an assessment interview would a nurse ask, "How does your faith help you in stressful situations?" During the assessment of: a. childhood growth and development. b. substance use and abuse. c. educational background. d. coping strategies.

ANS: D When discussing coping strategies, the nurse might ask what the patient does when upset, what usually relieves stress, and to whom the patient goes to talk about problems. The question regarding whether the patient's faith helps deal with stress fits well here. It would seem out of place if introduced during exploration of the other topics.

6. Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

ANS: A Of the options listed, the priority assessment is the victim's coping mechanisms. The other options have little relevance.

22. A patient with mental illness asks a psychiatric technician, "What's the matter with me?" The technician replies, "Your wing nuts need tightening." The patient looks bewildered and wanders off. The nurse who overheard the exchange should take action based on: a. violation of the patient's right to be treated with dignity and respect. b. the nurse's obligation to report caregiver negligence. c. preventing defamation of the patient's character. d. supervisory liability.

ANS: A Patients have the right to be treated with dignity and respect. Patients should never be made the butt of jokes about their illness. Patient emotional abuse has been demonstrated, not negligence. The technician's response was not clearly defamation. Patient abuse, not supervisory liability, is the issue.

24. A parent with schizophrenia and her 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child: a. displays resiliency. b. has a difficult temperament. c. is at risk for posttraumatic stress disorder. d. uses intellectualization to deal with problems.

ANS: A Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.

3. A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

4. A patient with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.

ANS: A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

6. A nurse's neighbor asks, "Why aren't people with mental illness kept in state institutions anymore?" What is the nurse's best response? a. "Many people are still in psychiatric institutions. Inpatient care is needed because many people who are mentally ill are violent." b. "Less restrictive settings are now available to care for individuals with mental illness." c. "Our nation has fewer persons with mental illness; therefore fewer hospital beds are needed." d. "Psychiatric institutions are no longer popular as a consequence of negative stories in the press."

ANS: B The community is a less restrictive alternative than hospitals for the treatment of people with mental illness. The remaining options are incorrect and part of the stigma of mental illness.

11. A patient 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 _____________ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

ANS: C The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis 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.

11. A newly admitted patient who is acutely psychotic is a private patient of the senior psychiatrist. To whom does the psychiatric nurse who is assigned to this patient owe the duty of care? a. Health care provider b. Profession c. Hospital d. Patient

ANS: D Although the nurse is accountable to the health care provider, the agency, the patient, and the profession, the duty of care is owed to the patient.

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

ANS: D The clouded sensorium, sensory perceptual distortions, and poor judgment increase the risk for injury. Safety is the nurse's priority. The scenario does not provide data to support the other diagnoses.

6. A nurse administers a medication that potentiates the action of gamma-aminobutyric acid (GABA). Which finding would be expected? a. Reduced anxiety b. Improved memory c. More organized thinking d. Fewer sensory perceptual alterations

ANS: A Increased levels of GABA reduce anxiety, thus any potentiation of GABA action should result in anxiety reduction. Memory enhancement is associated with acetylcholine and substance P. Thought disorganization is associated with dopamine. GABA is not associated with sensory perceptual alterations.

25. A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a. Teach the person to use positive self-talk. b. Assist the person to apply for disability benefits. c. Ask the person to explain why the fear is so disabling. d. Advise the person to accept the situation and use a companion.

ANS: A This intervention, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.

7. Which description best applies to a hallucination? A patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. becomes anxious when the nurse leaves his or her bedside. d. tries to hit the nurse when vital signs are taken.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The incorrect options are examples of behaviors that sometimes occur during delirium and are related to fluctuating levels of awareness and misinterpreted stimuli.

1. An alcohol-dependent patient was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)

ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.

10. A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess the lethality of a suicide plan. b. encourage expression of anger. c. establish a rapport with the patient. d. determine risk factors for suicide.

ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide.

7. A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.

ANS: C 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 illusions. Oral fluids are important, but safety is a higher priority.

29. Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations are decreased, and attention is impaired. The incorrect options describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.

24. A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered? a. Defensive coping b. Decisional conflict c. Risk for other-directed violence d. Impaired verbal communication

ANS: D The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.

17. When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. The alcohol is less potent. b. Tolerance develops. c. Antagonistic effects occur. d. Hypomagnesemia develops.

ANS: B 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 would account for this change.

17. A patient with stage 2 Alzheimer's disease calls the police saying, "An intruder is in my home." Police investigate and discover the patient misinterpreted a reflection in the mirror as an intruder. This phenomenon can be assessed as: a. hyperorality b. aphasia c. apraxia d. agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

2. A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: D Anxiety is the result of a personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Weak" is not a level of anxiety. Mild and moderate levels of anxiety allow the patient to function at a higher level.

2. A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis Situational low self-esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date) . b. consent to take antidepressant medication regularly by (date) . c. initiate social interaction with another person daily by (date) . d. identify two personal behaviors that alienate others by (date) .

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

4. A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented? a. Consistently demonstrated b. Often demonstrated c. Sometimes demonstrated d. Never demonstrated

ANS: D Although the patient is sleeping 6 hours daily, the total is not in one uninterrupted session at night. Therefore the outcome must be evaluated as never demonstrated.

1. A nurse wishes to teach alternative coping strategies to a patient who is experiencing severe anxiety. The nurse will first need to: a. Lower the patient's current anxiety level. b. Verify the patient's learning style. c. Create outcomes and a teaching plan. d. Assess how the patient uses defense mechanisms.

ANS: A A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.

5. A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient is unable to follow staff direction or respond to verbal interventions. Which nursing diagnosis has the highest priority? a. Risk for injury b. Self-care deficit c. Disturbed energy field d. Disturbed thought processes

ANS: A A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority.

28. The family of a patient with undifferentiated schizophrenia is unfamiliar with the illness and the family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medications, the significance of medication compliance, and the importance of support for the ill member of the family, and also provides recommendations for living with a person with schizophrenia. Such a group can be of practical assistance to the family members. The other types of therapy do not focus on psychoeducation.

35. A patient has a fear of public speaking. The nurse should be aware that social phobias are often treated with which type of medication? a. (beta)-blockers. b. Antipsychotic medications. c. Tricyclic antidepressant agents. d. Monoamine oxidase inhibitors.

ANS: A Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required.

28. Which statement is mostly likely to be made by a patient with agoraphobia? a. "Being afraid to go out seems ridiculous, but I can't go out the door." b. "I'm sure I'll get over not wanting to leave home soon. It takes time." c. "When I have a good incentive to go out, I can do it." d. "My family says they like it now that I stay home."

ANS: A Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

21. An older adult with moderate-stage dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult diapers. d. Make sure the older adult does not eat nonfood items.

ANS: A The patient with moderate Alzheimer's disease has memory loss that begins to interfere with activities. This patient may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the patient in disposable diapers is more appropriate as a later stage intervention. Making sure the patient does not eat nonfood items will be more relevant when the patient demonstrates hyperorality.

28. The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which reply by the nurse would be most helpful? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications.

4. When a patient with paranoid schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What common side effects should the nurse validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

1. A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

3. An individual is experiencing problems associated with memory. Which cerebral structures are most likely to be involved in this deficit? Select all that apply. a. Prefrontal cortex b. Occipital lobe c. Temporal lobe d. Parietal lobe e. Basal ganglia

ANS: A, C, D The prefrontal cortex, parietal, and temporal lobes of the cerebrum play a key role in the storage and processing of memories. The occipital lobe is predominantly involved with vision. The basal ganglia influence the integration of physical movement, as well as some thoughts and emotions.

1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

2. A student nurse caring for a patient with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

ANS: A, C, D, F Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self.

10. Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.4 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.

ANS: B A nontolerant drinker would be in a coma with a blood alcohol level of 400 mg/dl (0.40 mg %). The fact that the patient is walking and talking shows a discrepancy between blood alcohol level and expected behavior. It strongly suggests that the patient's body has become tolerant to the drug. If disulfiram and alcohol are ingested together, then an entirely different clinical picture would result. The blood alcohol level gives no information about the ingestion of other drugs.

8. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

7. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint? a. Dysthymia b. Anhedonia c. Euphoria d. Anergia

ANS: B Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means without energy.

7. Which nursing intervention demonstrates false imprisonment? a. A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and then promptly obtains an order. b. A patient has been irritating, seeking the attention of nurses most of the day. Now a nurse escorts the patient down the hall saying, "Stay in your room or you'll be put in seclusion." c. An involuntarily hospitalized patient with suicidal ideation runs out of the psychiatric unit. A nurse rushes after the patient and convinces the patient to return to the unit. d. An involuntarily hospitalized patient with suicidal ideation attempts to leave the unit. A nurse calls the security team and uses established protocols to prevent the patient from leaving.

ANS: B False imprisonment involves holding a competent person against his or her will. Actual force is not a requirement of false imprisonment. The individual needs only to be placed in fear of imprisonment by someone who has the ability to carry out the threat. The patient in one distracter is not competent, and the nurse is acting beneficently. The patients in the other distracters have been admitted as involuntary patients and should not be allowed to leave without permission of the treatment team.

12. What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

2. A patient has blindness related to a functional neurological (conversion) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? The patient is: a. suppressing accurate feelings regarding the problem. b. relieving anxiety through the physical symptom. c. meeting needs through hospitalization. d. refusing to disclose genuine fears.

ANS: B Psychoanalytic theory suggests conversion reduces anxiety through the production of a physical symptom that is symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously).

20. A patient has taken trifluoperazine (Stelazine) 30 mg/day orally for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts are observed. These symptoms are frequently not reversible, even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

23. An adult comes to the crisis clinic after being terminated 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

ANS: B The patient describes feelings of the 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 shown to be altered at this point.

4. A patient with blindness related to a functional neurological (conversion) disorder says, "All the doctors and nurses in this hospital stop by often to check on me. Too bad people outside the hospital don't find me interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

ANS: B The patient mentions that the symptoms make people more interested, which indicates that the patient believes he or she is uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of Chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in this scenario.

3. A patient diagnosed with paranoid schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

1. What are the primary distinguishing factors between the behavior of children with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? The child with: (select all that apply). a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

ANS: B, E Children with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas children with CD frequently behave in ways that violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with posttraumatic stress disorder. Stereotypical language behaviors are observed in autistic children. Separation problems with resultant anxiety occur with separation anxiety disorder.

2. A nurse at the mental health clinic plans a series of psychoeducational groups for persons with schizophrenia. Which two topics would take priority? a. How to complete an application for employment b. The importance of correctly taking your medication c. How to dress when attending community events d. How to give and receive compliments e. Ways to quit smoking

ANS: B, E Stabilization is maximized by the adherence to the antipsychotic medication regimen. Because so many patients with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiologic well-being. The other topics are also important but are not priority topics.

3. A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

ANS: C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

25. A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.

ANS: C Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.

2. An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

ANS: C Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

13. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in this adolescent's behavior? a. Bibliotherapy b. Play therapy c. Family therapy d. Art therapy

ANS: C Family therapy focuses on problematic family relationships and interactions. The patient has already identified problems within the family.

3. A patient who is experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a. "Why do you suppose you are feeling anxious?" b. "What would you like me to do to help you?" c. "I'm not sure I understand. Give me an example." d. "You must get your feelings under control before we can continue."

ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

35. A patient with schizophrenia has auditory hallucinations, delusions of grandeur, poor personal hygiene, and motor agitation. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Motor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia.

2. A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis. a. Imbalanced nutrition: Less than body requirements b. Chronic low self-esteem c. Risk for suicide d. Hopelessness

ANS: C Risk for suicide is the priority diagnosis when the patient has both suicidal ideation and a plan to carry out the suicidal intent. Imbalanced nutrition, Hopelessness, and Chronic low self-esteem may be applicable nursing diagnoses, but these problems do not affect patient safety as urgently as a suicide attempt.

32. Which finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild? The patient: a. Asks, "What's the matter with me?" b. Stays in a room alone and paces rapidly. c. Can concentrate on what the nurse is saying. d. States, "I don't want anything to eat. My stomach is upset."

ANS: C The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, "What's the matter with me?" Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.

2. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs! Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, although no sensory stimulus is actually present. This description coincides with the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take one dose of the antidepressant. Come to the clinic to see the health care provider." d. "Resume taking the antidepressant for 2 more weeks, and then discontinue them again."

ANS: C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

1. The admission note indicates a patient with depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

ANS: C, D, E Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

1. A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply. a. History of earlier suicide attempt b. Co-occurring medical illness c. Recent stressful life event d. Self-imposed isolation e. Shame or humiliation

ANS: C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommate's absence from the dormitory. Terminating access to one's social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness.

7. A health care provider considers which antipsychotic medication to prescribe for a patient with schizophrenia who has auditory hallucinations and poor social functioning. The patient is also overweight and has hypertension. Which drug should the nurse advocate? a. clozapine (Clozaril) b. ziprasidone (Geodon) c. olanzapine (Zyprexa) d. aripiprazole (Abilify)

ANS: D Aripiprazole is an atypical antipsychotic medication that is effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol levels, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

34. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states that a house fire is not likely. This counseling demonstrates the principles of: a. Flooding b. Desensitization c. Relaxation technique d. Cognitive restructuring

ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response.

7. On the basis of current knowledge of neurotransmitter effects, a nurse anticipates that the treatment plan for a patient with memory difficulties may include medications designed to: a. inhibit GABA production. b. increase dopamine sensitivity. c. decrease dopamine at receptor sites. d. prevent destruction of acetylcholine.

ANS: D Increased acetylcholine plays a role in learning and memory. Preventing the destruction of acetylcholine by acetylcholinesterase results in higher levels of acetylcholine with the potential for improved memory. GABA is known to affect anxiety level rather than memory. Increased dopamine causes symptoms associated with schizophrenia or mania rather than improves memory. Decreasing dopamine at receptor sites is associated with Parkinson disease rather than improving memory.

41. Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Perforated nasal septum and hypertension b. Drowsiness, euphoria, and constipation c. Pinpoint pupils and respiratory rate of 12 breaths per minute d. Confusion, mouth ulcers, and ataxia

ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid use.

6. A patient begins a new program to assist with building social skills. In which part of the plan of care should a nurse record the item "Encourage patient to attend one psychoeducational group daily"? a. Assessment b. Analysis c. Planning d. Implementation e. Evaluation

ANS: D Interventions are the nursing prescriptions to achieve the outcomes. Interventions should be specific.

26. A patient diagnosed with disorganized schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

15. 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.

ANS: D Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant.

11. Nursing behaviors associated with the implementation phase of the nursing process are concerned with: a. participating in the mutual identification of patient outcomes. b. gathering accurate and sufficient patient-centered data. c. comparing patient responses and expected outcomes. d. carrying out interventions and coordinating care.

ANS: D Nursing behaviors relating to implementation include using available resources, performing interventions, finding alternatives when necessary, and coordinating care with other team members.

16. For a patient with dissociative amnesia, complete this outcome: Within 4 weeks, the patient will demonstrate an ability to execute complex mental processes by: a. functioning independently." b. verbalizing feelings of safety." c. regularly attending diversional activities." d. describing previously forgotten experiences."

ANS: D The ability to recall previously repressed or dissociated material is an indication that the patient is integrating identity and memory. A patient may verbalize feeling safe but may be disoriented and have memory deficits. A patient may be able to function independently on a basic level without being able to remember significant information. Attending activities is possible without being able to remember antecedent events.

12. A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"

ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.

10. A woman says, "I can't take it 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 and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husband's infidelity d. Coping with the reaction to the daughter's events

ANS: D The focus of crisis intervention is on the most recent problem—"the straw that broke the camel's back." The patient has coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

10. Select the best outcome for a patient with the nursing diagnosis: Impaired social interaction, related to sociocultural dissonance as evidenced by stating, "Although I'd like to, I don't join in because I don't speak the language very well." The patient will: a. demonstrate improved social skills. b. express a desire to interact with others. c. become more independent in decision making. d. select and participate in one group activity per day.

ANS: D The outcome describes social involvement on the part of the patient. Neither cooperation nor independence has been an issue. The patient has already expressed a desire to interact with others. Outcomes must be measurable. Two of the distracters are not measurable.

13. A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

26. A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response? a. "I wonder what this sudden change is all about. Please tell me more." b. "I am glad you are feeling better. The team will consider your request." c. "You should not try to direct your care. Leave that to the treatment team." d. "Because we are concerned about your safety, we will continue with our plan."

ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process.

8. A patient with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts, and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory.

3. While caring for a patient with a methamphetamine overdose, which tasks are the priority focuses of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever

ANS: D, E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.

19. A patient says, "I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study." Which term should the nurse use to document this complaint? a. Depersonalization b. Hypochondriasis c. Dissociation d. Malingering

ANS: A Depersonalization involves a persistent or recurrent experience of feeling detached from and outside one's mental processes or body. Although reality testing is intact, the detached experience causes significant impairment in social or occupational functioning and distress to the individual. Malingering involves a conscious process of intentionally producing symptoms for an obvious benefit; dissociation is an unconscious defense mechanism to protect the individual against overwhelming anxiety. Hypochondriasis involves the interpretation of body sensations as symptomatic of a serious illness.

22. A patient's spouse, who is a chemist, asks a nurse how serotonin reuptake inhibitors (SSRIs) lift depression. The nurse should explain that SSRIs: a. destroy increased amounts of neurotransmitters. b. make more serotonin available at the synaptic gap. c. increase production of acetylcholine and dopamine. d. block muscarinic and alpha1-norepinephrine receptors.

ANS: A Depression is thought to be related to the lowered availability of the neurotransmitter serotonin. SSRIs act by blocking the reuptake of serotonin, leaving a higher concentration available at the synaptic cleft. They actually prevent the destruction of serotonin, have no effect on acetylcholine and dopamine production, and do not block muscarinic or alpha1-norepinephrine receptors.

19. An acutely violent patient with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position; the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore oral medication is not an option. Medication should be administered immediately; therefore the intramuscular route is best. In this case, the best option given is diphenhydramine.

8. A patient with depression is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should: a. explain how to manage hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. update the patient's mental status examination.

ANS: A Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Updating a mental status examination is unnecessary.

14. The treatment team plans care for a person diagnosed with paranoid schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each diagnosis primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the symptoms of schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.

ANS: A Dual diagnoses clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.

14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Establishing random eye movement latency d. Assisting the patient to identify and test negative thoughts

ANS: A During the immediate posttreatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Establishing random eye movement latency is neither possible nor a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the patient may be confused.

23. A nurse with a history of narcotic dependence is found unconscious in the hospital locker room after overdosing. The nurse is transferred to the inpatient chemical dependence unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance use. b. Pointing out that work problems are the result, but not the cause, of substance dependence. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.

ANS: A Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.

20. In the emergency department, a patient's vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.

ANS: A Hydromorphone (Dilaudid) is an opiate drug. The correct answer 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 distracters are desired outcomes later in the plan of care.

10. The therapeutic action of monoamine oxidase inhibitors (MAOIs) blocks neurotransmitter reuptake, causing: a. increased concentration of neurotransmitters in the synaptic gap b. decreased concentration of neurotransmitters in serum c. destruction of receptor sites d. limbic system stimulation

ANS: A If the reuptake of a substance is inhibited, then it accumulates in the synaptic gap and its concentration increases, permitting the ease of the transmission of impulses across the synaptic gap. Normal transmission of impulses across synaptic gaps is consistent with a normal rather than a depressed mood. The other options are not associated with blocking neurotransmitter reuptake.

3. A patient with major depression has lost 20 pounds in one month has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: "Patient will refrain from gestures and attempts to harm self"? a. Implement suicide precautions. b. Frequently offer high-calorie snacks and fluids. c. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication.

ANS: A Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.

12. A patient in the emergency department exhibits disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurse's office, furnished with chairs, files, magazines, and bookcases

ANS: A Individuals who are experiencing a severe-to-panic level of anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.

6. Shortly after an adolescent's parents announce a plan to divorce, the teen stops participating in sports, sits alone at lunch, and avoids former friends. The adolescent says, "If my parents loved me, then they would work out their problems." What nursing diagnosis is most applicable? a. Ineffective coping b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

ANS: A Ineffective coping is evident in the adolescent's response to family stress and discord. Adolescents value peer interactions, and yet this child has eliminated that source of support. The distracters are not supported by the data in this scenario.

5. A nurse works with a patient with paranoid schizophrenia regarding the importance of medication management. The patient repeatedly says, "I don't like taking pills." Family members say they feel helpless to foster compliance. Which treatment strategy should the nurse discuss with the health care provider? a. Use of a long-acting antipsychotic preparation b. Addition of a benzodiazepine, such as lorazepam (Ativan) c. Adjunctive use of an antidepressant, such as amitriptyline (Elavil) d. Prolonged hospitalization; this patient is not ready for discharge

ANS: A Medications such as fluphenazine decanoate and haloperidol decanoate are long-acting forms of antipsychotic medications. They are administered by depot injection every 2 to 4 weeks, thus reducing daily opportunities for noncompliance. The other options do not address the patient's dislike of taking pills.

16. A drug causes muscarinic-receptor blockade. A nurse will assess the patient for: a. dry mouth b. gynecomastia c. pseudoparkinsonism d. orthostatic hypotension

ANS: A Muscarinic-receptor blockade includes atropine-like side effects such as dry mouth, blurred vision, and constipation. Gynecomastia is associated with decreased prolactin levels. Movement defects are associated with dopamine blockade. Orthostatic hypotension is associated with alpha1-receptor antagonism.

21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient with an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.

ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer span of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.

33. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.

ANS: A Patients who have ingested LSD respond well to being "talked down" by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.

14. A patient has progressive memory deficit associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Promote the use of the patient's sense of humor by telling jokes or riddles.

ANS: A Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may lose their sense of humor and find jokes and riddles meaningless.

23. Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."

ANS: A Patients with eating disorders have distorted body images; they see themselves as overweight even when their weight is subnormal. "I'm thin for my height" is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as "I have nice eyes." Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. illusion b. delusion c. hallucinations d. hypnagogic phenomenon

ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.

13. A nurse assesses a patient diagnosed with functional neurological (conversion) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

ANS: A Patients with functional neurologic (conversion) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed "la belle indifférence." In addition, a specific cause for the development of the symptoms is identifiable; in this instance, the death of a parent precipitates the stress.

18. Which statement most accurately describes substance dependence? a. It is a lack of control over use. Tolerance and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the work of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves taking a combination of substances to weaken or inhibit the effect of another drug.

ANS: A Psychoactive substance dependence involves a lack of control over use, as well as tolerance and withdrawal symptoms when intake is reduced or stopped.

20. An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a. Rationalization b. Compensation c. Introjection d. Regression

ANS: A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

19. A person who is speaking about a rival for a significant other's affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. Reaction formation b. Repression c. Projection d. Denial

ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

27. A patient with major depression was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion are associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient him- or herself to a pressured work schedule.

ANS: A Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient him- or herself to a pressured work schedule is less relevant than the correct rationale.

26. Which comment by a person who is experiencing severe anxiety indicates the possibility of obsessive-compulsive disorder? a. "I check where my car keys are eight times." b. "My legs often feel weak and spastic." c. "I'm embarrassed to go out in public." d. "I keep reliving the car accident."

ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, "My legs feel weak most of the time," is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder.

20. An 11-year-old child, who has been diagnosed with oppositional defiant disorder ODD, becomes angry over the rules at a residential treatment program and begins shouting at the nurse. Select the best method to defuse the situation. a. Suggest that the child go to the gym and shoot baskets. b. Administer an antipsychotic medication. c. Place the child in a basket-hold. d. Call a staff member to seclude the child.

ANS: A Redirecting the expression of feelings into nondestructive age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This method is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures.

4. A patient with a high level of motor activity runs from chair to chair and cries, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a. provide for patient safety. b. increase environmental stimuli. c. respect the patient's personal space. d. encourage the clarification of feelings.

ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self-injury related to an increase in non-goal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patient's personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered.

14. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then visit every other day for 1 week; stay with the patient for 20 minutes; accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option, yet important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

4. An adult with depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

ANS: A Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patient's support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.

15. Which assessment finding would cause the nurse to consider an 8-year-old child to be most at risk for the development of a psychiatric disorder? a. Being raised by a parent with chronic major depression b. Moving to three new homes over a 2-year period c. Not being promoted to the next grade d. Having an imaginary friend

ANS: A Statistics tell us that children raised by a depressed parent have a 30% to 50% chance of developing an emotional disorder. The chronicity of the parent's depression means it has been a consistent stressor. The other factors do not create ongoing stress.

40. Which documentation indicates that the treatment plan for a patient in an alcohol rehabilitation program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety 1 day at a time." Spoke with employer, who is willing to allow the patient to return to work in 3 weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and states, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."

ANS: A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.

18. A 12-year-old child has been the neighborhood bully for several years. The parents say, "We can't believe anything our child says." Recently, the child shot a dog with a pellet gun and set fire to a trash bin outside a store. The child's behaviors are most consistent with: a. conduct disorder CD. b. attention deficit ADHD. c. defiance of authority. d. anxiety over separation from a parent.

ANS: A The behaviors mentioned are most consistent with the DSM-IV-TR criteria for CD: aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. The behaviors are not consistent with ADHD and separation anxiety and are more pervasive than defiance of authority.

23. Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

ANS: A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

6. A college student who attempts suicide by overdose is hospitalized. When the parents are contacted they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects: a. denial. b. anger. c. anxiety. d. rescue feelings.

ANS: A The parents' statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distracters are not clearly described in the scenario.

4. A 16-year-old adolescent with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a. The teen and parents create and consent to a behavioral contract with rules, rewards, and consequences. b. The teen completes an application to enter a military academy for continued structure and discipline. c. The teen is temporarily placed with a foster family until the parents complete a parenting skills class. d. The teen has an absence of anger and frustration for 1 week.

ANS: A The patient and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The patient will continue to experience anger and frustration. The patient and parents must continue with family therapy to work on boundary and communication issues. Separating the patient from the family to work on these issues is not necessary, and separation is detrimental to the healing process.

14. An adolescent is arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all their attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Ineffective coping, related to seeking parental attention as evidenced by acting out b. Disturbed personal identity, related to acting out as evidenced by prostitution c. Impaired parenting, related to showing preference for one child over another d. Hopelessness, related to feeling unloved by parents

ANS: A The patient demonstrates an inability to problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient has never mentioned hopelessness, low self-esteem, or disturbed personal identity.

11. 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."

ANS: A The patient in a fugue state frequently relocates and assumes a new identity while not recalling his or her previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

8. An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy on the unit. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider the discontinuation of suicide precautions.

ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient must be supervised 24 hours per day; the patient is still a suicide risk.

13. A patient with delusions of persecution about being poisoned has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient to have supervised access to food vending machines b. Allowing the patient to telephone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are considered aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safe.

18. When a nurse assesses an older adult patient, answers seem vague or unrelated to the questions. The patient also leans forward and frowns, listening intently to the nurse. An appropriate question for the nurse to ask would be: a. "Are you having difficulty hearing when I speak?" b. "How can I make this assessment interview easier for you?" c. "I notice you are frowning. Are you feeling annoyed with me?" d. "You're having trouble focusing on what I'm saying. What is distracting you?"

ANS: A The patient's behaviors may indicate difficulty hearing. Identifying any physical need the patient may have at the onset of the interview and making accommodations are important considerations. By asking if the patient is annoyed, the nurse is jumping to conclusions. Asking how to make the interview easier for the patient may not elicit a concrete answer. Asking about distractions is a way of asking about auditory hallucinations, which is not appropriate because the nurse has observed that the patient seems to be listening intently.

24. The laboratory report for a patient taking clozapine (Clozaril) shows a white blood cell count of 3000 mm3 and a granulocyte count of 1500 mm3. The nurse should: a. report the laboratory results to the health care provider. b. give the next dose as prescribed. c. administer aspirin and force fluids. d. repeat the laboratory tests.

ANS: A These laboratory values indicate the possibility of agranulocytosis, a serious side effect of clozapine therapy. These results must be immediately reported to the health care provider. The drug should be withheld because the health care provider will discontinue it. The health care provider may repeat the laboratory test, but, in the meantime, the drug should be withheld. Giving aspirin and forcing fluids are measures that are less important than stopping the administration of the drug.

21. Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Jumping from a 100-foot-high railroad bridge located in a deserted area late at night b. Turning on the oven and letting gas escape into the apartment during the night c. Cutting the wrists in the bathroom while the spouse reads in the next room d. Overdosing on aspirin with codeine while the spouse is out with friends

ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.

4. A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell others perceptions of self. The patient with anorexia will persist in trying to lose more weight.

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

14. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to answer questions. Select the nurse's best action. a. Document the patient's mental status. Obtain other assessment data from the family member. b. Record the patient's answers to questions on the nursing assessment form. c. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient's rights.

ANS: A When the patient (primary source) is unable to provide information, secondary sources should be used, in this case the family member. Later, more data may be obtained from other relatives or neighbors who are familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.

23. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, which are the symptoms present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

3. A patient with paranoid schizophrenia is hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof and suspicious and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of Disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by "yes" or "no."

2. A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply. a. Allow no glass or metal on meal trays. b. Remove all potentially harmful objects from the patient's possession. c. Maintain arm's length, one-on-one nursing observation around the clock. d. Check the patient's whereabouts every hour. Make verbal contact at least three times each shift. e. Check the patient's whereabouts every 15 minutes, and make frequent verbal contacts. f. Keep the patient within visual range while he or she is awake. Check every 15 to 30 minutes while the patient is sleeping.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patient's possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions.

3. A patient with major depression will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply. a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. d. Restrain the patient in bed with padded limb restraints. e. Assist the patient to prepare an advance directive.

ANS: A, B, C The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment.

5. A patient being treated with paroxetine (Paxil) 50 mg/day orally for depression reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Increased suicidal ideation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

ANS: A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected.

1. A patient with Alzheimer's disease has a dressing and grooming self-care deficit. Designate the appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and the name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items, and direct the patient to proceed independently. e. If the patient resists, use distraction and then try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates patient independence. Labeling clothing with the patient's name and the name of the item maintains patient identity and dignity (and provides information if the patient has agnosia). When a patient resists, using distraction and trying again after a short interval are appropriate because patient moods are often labile; the patient may be willing to cooperate during a later opportunity. Providing the necessary items for grooming and directing the patient to proceed independently are inappropriate. Staff members are prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

2. A nurse performing an assessment interview for a patient with a substance use disorder decides to use a standardized rating scale. Which scales are appropriate? Select all that apply. a. Addiction Severity Index (ASI) b. Brief Drug Abuse Screen Test (B-DAST) c. Abnormal Involuntary Movement Scale (AIMS) d. Cognitive Capacity Screening Examination (CCSE) e. Recovery Attitude and Treatment Evaluator (RAATE)

ANS: A, B, E Standardized scales are useful for obtaining data concerning substance use disorders. The ASI, B-DAST, and RAATE are scales related to substance abuse. The AIMS assesses involuntary movements associated with antipsychotic medications. The CCSE assesses cognitive function.

1. A child is placed in a foster home after being removed from parental contact because of abuse. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. What should the nurse recommend? Select all that apply. a. Use a calm manner and low voice. b. Maintain simplicity in the environment. c. Avoid repetition in what is said to the child. d. Minimize opportunities for exercise and play. e. Explain and reinforce reality to avoid distortions.

ANS: A, B, E The child can be hypothesized to have moderate-to-severe trait (chronic) anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns.

3. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white man b. 17-year-old white female adolescent c. 39-year-old African-American man d. 29-year-old African-American woman e. 22-year-old man with traumatic brain injury

ANS: A, B, E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury.

2. A nurse can assist a patient and family in which aspects of substance abuse relapse prevention? 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. Isolating self from significant others and social situations until sobriety is established e. Teaching the patient about the 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. The nurse can participate in role playing and help the patient evaluate the usefulness of new strategies. The nurse can also provide valuable information about the physiologic changes that can be expected and the ways in which 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.

2. A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

1. A nurse prepares to administer an antipsychotic medication to a patient with schizophrenia. Additional monitoring of the medication's effects and side effects will be most important if the patient is also diagnosed with which health problem? Select all that apply. a. Parkinson disease b. Graves disease c. Osteoarthritis d. Epilepsy e. Diabetes

ANS: A, D, E Antipsychotic medications may produce weight gain, which complicates the care of a patient with diabetes or lowers the seizure threshold or both, which complicates the care of a patient with epilepsy. Parkinson disease involves changes in transmission of dopamine and acetylcholine; therefore these drugs also complicate the care of a patient with the disorder. Osteoarthritis and Graves disease should have no synergistic effect with this medication.

1. A patient with predominant pain disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

ANS: A, E The patient's verbalization is consistent with spiritual distress. Moreover, the patient's description of being unable to provide for and burdening the family suggests ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict.

10. A nurse encourages an anxious patient to talk about feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and defuses the patient's anxiety. b. Concerns stated aloud become less overwhelming and help problem solving to begin. c. Anxiety is reduced by focusing on and validating what is occurring in the environment. d. Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin.

5. A priority intervention for a patient with major depression is: a. distracting the patient from self-absorption. b. carefully and unobtrusively observing the patient around the clock. c. allowing the patient to spend long periods alone in meditation. d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.

ANS: B Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit.

15. A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing? a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances

ANS: B Assessing cognition involves determining a patient's judgment and decision-making capabilities. In this case, the nurse expects a response of, "Call my doctor" if the patient's cognition and judgment are intact. If the patient responds, "I would stop eating" or "I would just wait and see what happened," the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.

7. Before assessing a new patient, a nurse is told by another health care worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge." The nurse's responsibility is to: a. document the other worker's assessment of the patient. b. assess the patient based on data collected from all sources. c. validate the worker's impression by contacting the patient's significant other. d. discuss the worker's impression with the patient during the assessment interview.

ANS: B Assessment should include data obtained from both the primary and reliable secondary sources. Biased assessments by others should be evaluated as objectively as possible by the nurse, keeping in mind the possible effects of counter-transference.

30. A patient performs ritualistic hand washing. What should the nurse do to help the patient develop more effective coping strategies? a. Allow the patient to set a hand-washing schedule. b. Encourage the patient to participate in social activities. c. Encourage the patient to discuss hand-washing routines. d. Focus on the patient's symptoms rather than on the patient.

ANS: B Because patients with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patient's coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom.

17. A person comes to the clinic reporting, "I wear a scarf across my lower face when I go out but because of my ugly appearance." Assessment reveals an average appearance with no actual disfigurement. Which problem is most likely? a. Dissociative identity disorder b. Body dysmorphic disorder c. Pseudocyesis d. Malingering

ANS: B Body dysmorphic disorder involves a preoccupation with an imagined defect in appearance. Dissociative identity disorder involves the existence of two or more distinct subpersonalities, each with its own patterns of relating, perceiving, and thinking. Pseudocyesis is the false belief that one is pregnant. Malingering is intentionally producing symptoms for a personal gain.

36. A patient tells the nurse, "I wanted my health care provider to prescribe diazepam (Valium) for my anxiety disorder, but buspirone (BuSpar) was prescribed instead. Why?" The nurse's reply should be based on the knowledge that buspirone: a. Does not produce blood dyscrasias. b. Does not cause dependence. c. Can be administered as needed. d. Is faster acting than diazepam.

ANS: B Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone.

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police took the person home, the spouse reported frequent wandering into neighbors' homes. Alzheimer's disease was subsequently diagnosed. Which stage of Alzheimer's disease is evident? a. 1 (mild) b. 2 (moderate) c. 3 (moderate to severe) d. 4 (late)

ANS: B In stage 2 (moderate), deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. Hygiene may begin to deteriorate. Stage 3 (moderate to severe) finds the individual unable to identify familiar objects or people and needing direction for the simplest of tasks. In stage 4 (late) the ability to talk and walk are eventually lost and stupor evolves.

25. A patient who was hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event? a. Request the public information officer to make an announcement to the local media. b. Hold a staff meeting to express feelings and plan the care for other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Quickly discharge as many patients as possible to prevent panic.

ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care.

38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"

ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.

34. A patient with schizophrenia begins a new prescription for lurasidone HCl (Latuda). The patient is 5', 6" tall and currently weighs 204 pounds. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCl (Latuda) is an atypical antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management is especially important. The incidence of tardive dyskinesia is low with atypical antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

11. A patient taking medication for mental illness develops restlessness and an uncontrollable need to be in motion. A nurse can correctly analyze that these symptoms are related to which drug action? a. Anticholinergic effects b. Dopamine-blocking effects c. Endocrine-stimulating effects d. Ability to stimulate spinal nerves

ANS: B Medications that block dopamine often produce disturbances of movement such as akathisia because dopamine affects neurons involved in both the thought processes and movement regulation. Anticholinergic effects include dry mouth, blurred vision, urinary retention, and constipation. Akathisia is not caused by endocrine stimulation or spinal nerve stimulation.

23. During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent

ANS: B Mood is a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

11. An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

ANS: B One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

3. A patient with major depression says, "No one cares about me anymore. I'm not worth anything." The nurse wants to reinforce positive self-esteem. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you're wearing." d. "You must be feeling better today."

ANS: B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as an observation avoid negative interpretations. Saying "You look nice" or "I like your shirt" gives approval (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic.

22. Which symptoms are expected for a patient with disorganized schizophrenia? a. Extremes of motor activity, from excitement to stupor b. Social withdrawal and ineffective communication c. Severe anxiety with ritualistic behavior d. Highly suspicious, delusional behavior

ANS: B Patients with disorganized schizophrenia demonstrate the most regressed and socially impaired behaviors of the schizophrenias. Communication is often incoherent, with silly giggling and loose associations predominating. Highly suspicious, delusional behavior relates more to paranoid schizophrenia. Extremes of motor activity, from excitement to stupor, relates to catatonic schizophrenia. Severe anxiety and ritualistic behaviors relate to obsessive-compulsive disorder.

13. Which entry in the medical record best meets the requirement for problem-oriented charting? a. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV." b. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV." c. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV." d. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"

ANS: B Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The distracters offer examples of PIE charting, focus documentation, and narrative documentation.

30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia b. paranoid delusions, tactile hallucinations, and panic c. runny nose, yawning, insomnia, and chills d. anxiety, agitation, and aggression

ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, minus the temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.

9. A patient with a somatic symptom disorder has the nursing diagnosis: Interrupted family processes, related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. Assume roles and functions of the other family members. b. Demonstrate a resumption of former roles and tasks. c. Focus energy on problems occurring in the family. d. Rely on family members to meet his or her personal needs.

ANS: B The patient with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and the resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes.

4. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Bathing/hygiene self-care deficit, related to altered cerebral function, as evidenced by confusion and inability to perform personal hygiene tasks b. Risk for injury, related to altered cerebral function, misperception of the environment, and unsteady gait c. Disturbed thought processes, related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear, related to sensory perceptual alterations, as evidenced by hiding from imagined ferocious dogs

ANS: B The physical safety of the patient is the highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful; when the patient exercises poor judgment; and when the patient's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

1. A patient undergoing alcohol rehabilitation decides to accept disulfiram (Antabuse) therapy to avoid impulsively responding to drinking cues. Which information should be included in the discharge teaching for this patient? Select all that apply. a. Avoid aged cheeses. b. Read labels of all liquid medications. c. Wear sunscreen and avoid bright sunlight. d. Maintain an adequate dietary intake of sodium. e. Avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, E 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, beer, or spirits of any sort may also trigger reactions. The other options do not relate to hidden sources of alcohol.

10. A woman is 5'7" tall, weighs 160 pounds, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." The patient tries to buy shoes to make her feet look smaller, and in social settings conceals both feet under a table or chair. Which health problem is likely? a. Dissociative fugue b. Prominent pain disorder c. Body dysmorphic disorder d. Depersonalization disorder

ANS: C Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of her body. Dissociative fugue is characterized by sudden, unexpected travel away from the customary locale and the inability to recall one's identity and information about some or all of the past. Prominent pain disorder involves the presence of pain not associated with a medical disorder. Depersonalization disorder involves an alteration in the perception of self, such as feeling mechanical or unreal.

5. What is the priority intervention for a patient with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Avoidance of physical contact b. High level of sensory stimulation c. Careful observation and supervision d. Application of wrist and ankle restraints

ANS: C Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient remains safe and free from injury while hospitalized. Physical contact during care cannot be avoided. Restraint is a last resort, and sensory stimulation should be reduced.

6. When counseling patients with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

ANS: C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned.

27. A patient with predominant pain disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as: a. unsuccessful. b. minimally successful. c. partially successful. d. totally achieved.

ANS: C Decreased preoccupation with symptoms and an increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of patient resistance.

5. The nurse wants to assess for disturbances in circadian rhythms in a patient admitted for depression. Which question best implements this assessment? a. "Do you ever see or hear things that others do not?" b. "Do you have problems with short-term memory?" c. "What are your worst and best times of day?" d. "How would you describe your thinking?"

ANS: C Mood changes throughout the day are related to circadian rhythms. Questions about sleep pattern would also be relevant to circadian rhythms. The question about seeing or hearing things is relevant to the assessment for illusions and hallucinations. The question about thinking is relevant to the assessment of thought processes. The other question is relevant to assessment of memory.

2. A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the patient has nowhere else to go.

16. While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing the symptoms of hypokalemia. d. self-esteem maintenance.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

15. A patient tells a nurse, "My new friend is the most perfect person one could imagine—kind, considerate, and good looking. I can't find a single flaw." This patient is demonstrating: a. denial. b. projection. c. idealization. d. compensation.

ANS: C Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

17. When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options.

16. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Place large clocks and calendars on the wall. b. Place personally meaningful objects in view. c. Use the patient's glasses and hearing aids. d. Keep the room brightly lit at all times.

ANS: C Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

24. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Maintenance of nutrition and hydration d. Prevention of the patient from wandering

ANS: C In late-stage dementia, the patient often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the patient is to live. The patient is incapable of self-care, ambulation, or verbal communication.

29. A patient has the nursing diagnosis: Anxiety, related to __________, as evidenced by an inability to control compulsive cleaning. Which phrase correctly completes the etiologic portion of the diagnosis? a. Ensuring the health of household members b. Attempting to avoid interactions with others c. Having persistent thoughts about bacteria, germs, and dirt d. Needing approval for cleanliness from friends and family

ANS: C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.

20. When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in: a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.

ANS: C Milieu management provides a therapeutic environment in which the patient can feel comfortable and safe while engaging in activities that meet the patient's physical and mental health needs. Counseling refers to activities designed to promote problem solving and enhanced coping and includes interviewing, crisis intervention, stress management, and conflict resolution. Health teaching involves identifying health educational needs and giving information about these needs. Psychobiologic interventions involve medication administration and monitoring response to medications.

15. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. Monitors sodium intake and weight daily. b. Wears support stockings and elevates the legs when sitting. c. Consults the pharmacist when selecting over-the-counter medications. d. Can identify foods with high selenium content, which should be avoided.

ANS: C Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with an eating disorder not otherwise specified may be obese.

1. A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients? a. Perform mental health assessment interviews. b. Establish therapeutic relationships. c. Prescribe psychotropic medications. d. Individualize nursing care plans.

ANS: C Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning.

14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a. Introjection b. Conversion c. Projection d. Splitting

ANS: C Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

21. A patient with predominant pain disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess: a. Mood b. Cognitive style c. Secondary gains d. Identity and memory

ANS: C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the patient's diagnosis has been established.

6. A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine

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

15. Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "I know what you're up to; you're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither patient loses self-esteem during this intervention. Medication is probably not necessary. Stepping between two angry, threatening patients is an unsafe action, and trying to reinforce reality during an angry outburst will probably not be successful when the patients are cognitively impaired.

21. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a pool ball at another adolescent, which comment by the nurse would set limits? a. "Attention, everyone. We are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

ANS: C Setting limits uses clear, sharp statements about the prohibited behavior and provides guidance for performing a behavior that is expected. The incorrect options represent a threat, use restructuring (which would be inappropriate in this instance), and make a direct appeal to the child's developing self-control that may be ineffective.

5. To assist a patient with a somatic system disorder, a nursing intervention of high priority is to: a. imply that somatic symptoms are not real. b. help the patient suppress feelings of anger. c. shift the focus from somatic symptoms to feelings. d. investigate each physical symptom as it is offered.

ANS: C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys an interest in the patient as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome is that the patient expresses feelings, including anger, if it is present. Once physical symptoms have been investigated, they do not need to be reinvestigated each time the patient reports them.

25. Which intervention is appropriate to use for patients with either delirium or dementia? a. Speak in a loud, firm voice. b. Touch the patient before speaking. c. Reintroduce the health care worker at each contact. d. When the patient becomes aggressive, use physical restraint instead of medication.

ANS: C Short-term memory is often impaired in patients with delirium and dementia. Reorientation to staff is often necessary with each contact to minimize misperceptions, reduce anxiety level, and secure cooperation. Loud voices may be frightening or sound angry. Speaking before touching prevents the patient from feeling threatened. Physical restraint is not appropriate; the least restrictive measure should be used.

16. A newly admitted patient with schizophrenia says, "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices." d. "Forget the voices, and ask some other patients to play cards with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

12. Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Completing a psychologic postmortem assessment c. Attending a self-help group for survivors d. Contracting for two sessions of group therapy

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychologic postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide.

25. A nurse administering psychotropic medications should be prepared to intervene when giving a drug that blocks the attachment of norepinephrine to alpha1 receptors because the patient may experience: a. increased psychotic symptoms b. severe appetite disturbance c. orthostatic hypotension d. hypertensive crisis

ANS: C Sympathetic-mediated vasoconstriction is essential for maintaining normal blood pressure in the upright position. Blockage of alpha1 receptors leads to vasodilation and orthostatic hypotension. Orthostatic hypotension may cause fainting and falls. Patients should be taught ways of minimizing this phenomenon.

4. A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate assessment of the 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 a recurrence of an acute psychosis.

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

16. An adolescent asks a nurse conducting an assessment interview, "Why should I tell you anything? You'll just tell my parents whatever you find out." Select the nurse's best reply. a. "That isn't true. What you tell us is private and held in strict confidence. Your parents have no right to know." b. "Yes, your parents may find out what you say, but it is important that they know about your problems." c. "What you say about feelings is private, but some things, like suicidal thinking, must be reported to the treatment team." d. "It sounds as though you are not really ready to work on your problems and make changes."

ANS: C The patient has a right to know that most information will be held in confidence but that certain material must be reported or shared with the treatment team, such as threats of suicide, homicide, use of illegal drugs, or issues of abuse. The first response is not strictly true. The second response will not inspire the confidence of the patient. The fourth response is confrontational.

19. The parent of a child with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

ANS: C Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency and severity and are reduced or absent during sleep.

22. When a 5-year-old child is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next meal. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

ANS: C Time-out is designed so that staff can be consistent in their interventions. Time-out may require having the child sit on the periphery of an activity until he or she gains self-control and reviews the episode with a staff member. Time-out may not require having the child go to a designated room and does not involve special attention such as holding. Having the child count to 10 or 20 is not sufficient.

3. A patient's roommate has observed the patient behaving in uncharacteristic ways, but the patient cannot remember the episodes. A dissociative identity disorder is suspected. Which questions are most relevant to the assessment of this patient? Select all that apply. a. "Are you sexually promiscuous?" b. "Do you think you need an antidepressant medication?" c. "Have you ever found yourself someplace and did not know how you got there?" d. "Are your memories of childhood clear and complete, or do you have blank spots?" e. "Have you ever found new things in your belongings that you can't remember buying?"

ANS: C, D, E Asking, "Are you sexually promiscuous?" would probably produce defensiveness on the part of the patient. If a subpersonality acts out sexually, the main personality is probably not aware of the behavior. "Do you think you need an antidepressant medication?" is a premature question and not in the nurse's scope of practice. All of the other questions are pertinent.

2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient's eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

8. To plan effective care for patients with somatic system disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. Are generally chronic. b. Have a physiological basis. c. Can be voluntarily controlled. d. Provide relief from health anxiety.

ANS: D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide a secondary gain, patients frequently and fiercely cling to the symptoms. The symptoms tend to be chronic; however, this does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based.

23. A patient has taken many conventional antipsychotic drugs over years. The health care provider, who is concerned about early signs of tardive dyskinesia, prescribes risperidone (Risperdal). A nurse planning care for this patient understands that atypical antipsychotics: a. are less costly. b. have higher potency. c. are more readily available. d. produce fewer motor side effects.

ANS: D Atypical antipsychotic drugs often exert their action on the limbic system rather than the basal ganglia. The limbic system is not involved in motor disturbances. Atypical antipsychotic medications are not more readily available. They are not considered to be of higher potency; rather, they have different modes of action. Atypical antipsychotic drugs tend to be more expensive.

25. A parent with schizophrenia and 13-year-old child live in a homeless shelter. The child has formed a trusting relationship with a volunteer. The teen says, "I have three good friends at school. We talk and sit together at lunch." What is the nurse's best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from the domestic violence program. c. Make referrals for existing and emerging developmental problems. d. Foster healthy characteristics and existing environmental supports.

ANS: D Because the teenager shows no evidence of poor mental health, the best action would be to foster existing healthy characteristics and environmental supports. No other option is necessary or appropriate under the current circumstances.

2. Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

12. Which patient with schizophrenia would be expected to have the lowest score in global assessment of functioning? a. 39 years old; paranoid ideation since age 35 years b. 32 years old; diagnosed as catatonic at age 24 years; stable for 3 years c. 19 years old; diagnosed with undifferentiated schizophrenia at age 17 d. 40 years old; disorganized schizophrenia since age 18; frequent relapses

ANS: D Disorganized schizophrenia represents the most regressed and socially impaired of all the schizophrenias. The 40-year-old patient who has had disorganized schizophrenia since 18 years of age could logically be expected to have the lowest global assessment of functioning. In addition, the patient has been ill for a number of years and has had frequent relapses. The 39-year-old patient who has had paranoid ideation since 35 years of age could be expected to have the highest score, because paranoid schizophrenia of short duration may be less impairing than other types. The patient who was diagnosed as catatonic at the age of 24 years has been stable for more than 3 years, suggesting a higher functional ability. The 19-year-old patient who was diagnosed with undifferentiated schizophrenia at 17 years of age has been ill for only 2 years, and disability in undifferentiated schizophrenia remains fairly stable over time.

17. A nurse assessing a new patient asks, "What is meant by the saying, 'You can't judge a book by its cover'?" Which aspect of cognition is the nurse assessing? a. Mood b. Attention c. Orientation d. Abstraction

ANS: D Patient interpretation of proverbial statements gives assessment information regarding the patient's ability to abstract, which is an aspect of cognition. Mood, orientation, and attention span are assessed in other ways.

17. A patient begins therapy with a phenothiazine medication. What teaching should a nurse provide related to the drug's strong dopaminergic effect? a. Chew sugarless gum. b. Increase dietary fiber. c. Arise slowly from bed. d. Report muscle stiffness.

ANS: D Phenothiazines block dopamine receptors in both the limbic system and basal ganglia. Dystonia is likely to occur early in the course of treatment and is often heralded by sensations of muscle stiffness. Early intervention with an antiparkinsonian medication can increase the patient's comfort and prevent dystonic reactions.

23. Which documentation of a patient's behavior best demonstrates a nurse's observations? a. Isolates self from others. Frequently fell asleep during group. Vital signs stable. b. Calmer and more cooperative. Participated actively in group. No evidence of psychotic thinking. c. Appeared to hallucinate. Patient frequently increased volume on television, causing conflict with others d. Wears four layers of clothing. States, "I need protection from dangerous bacteria trying to penetrate my skin."

ANS: D The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.

6. A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Antisocial personality disorder c. Simple somatic symptom disorder d. Prominent health anxiety (hypochondriasis)

ANS: D Prominent health anxiety (hypochondriasis) involves a preoccupation with fears of having a serious disease, even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Simple somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others.

26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.

ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.

9. A nursing care plan for a patient with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

ANS: D Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

10. A 4-year-old child cries and screams from the time the parents leave the child at preschool until the child is picked up 4 hours later. The child is calm and relaxed when the parents are present. The parents ask, "What should we do?" What is the nurse's best recommendation? a. "Send a picture of yourself to school to keep with the child." b. "Arrange with the teacher to let the child call home at playtime." c. "Talk with the school about withdrawing the child until maturity increases." d. "Talk with your health care provider about a referral to a mental health clinic."

ANS: D Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. Often, the first time separation occurs is when the child goes to kindergarten or nursery school. Separation anxiety may be based on the child's fear that something will happen to the attachment figure. The child needs professional help.

29. A patient with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "Volmers are hiding in the house." The nurse can correctly assess this information as an indication of: a. need for psychoeducation b. medication noncompliance c. chronic deterioration d. relapse

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is regularly taking his or her medication. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.

5. A patient's nursing diagnosis is Insomnia. The desired outcome is: "Patient will sleep for a minimum of 5 hours nightly by October 31." On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. What is the nurse's next action? a. Continue the current plan without changes. b. Remove this nursing diagnosis from the plan of care. c. Write a new nursing diagnosis that better reflects the problem. d. Revise the target date for outcome attainment and examine interventions.

ANS: D Sleeping a total of 5 hours at night remains a reasonable outcome. Extending the time frame for attaining the outcome is appropriate. Examining interventions might result in planning an activity during the afternoon rather than permitting a nap. Continuing the current plan without changes is inappropriate. At the very least, the time in which the outcome is to be attained must be extended. Removing this nursing diagnosis from the plan of care could be used when the outcome goal has been met and the problem resolved. Writing a new nursing diagnosis is inappropriate because no other nursing diagnosis relates to the problem.

33. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 10:30 AM. By noon, the patient has difficulty swallowing and is drooling. By 4:00 PM, vital signs are body temperature, 102.8° F; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis. Institute reverse isolation. b. Tardive dyskinesia. Withhold the next dose of medication. c. Cholestatic jaundice. Begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome. Immediately notify the health care provider.

ANS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in this scenario are not consistent with the medical problems listed in the incorrect options.

26. A patient with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." The nurse should help the patient by: a. encouraging meditation. b. administering an anxiolytic medication. c. helping the patient visualize a pleasant scene. d. helping the patient focus on the here and now.

ANS: D Talking with someone who can help the patient focus on reality allows the patient to interrupt the stimulus to dissociate. The incorrect options foster detachment.

10. A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

ANS: D The correct response is the only strategy that attempts to question the patient's distorted thinking.

8. An alcohol-dependent individual says, "Drinking helps me cope with being a single parent." Which response by the nurse would help the individual conceptualize the drinking more 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 individual is rationalizing. The correct response will help the patient see alcohol as a cause of the problems, not the solution. This approach can also help the patient become receptive to the possibility of change. The incorrect responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

2. The parent of an adolescent with schizophrenia asks a nurse, "My child's doctor ordered a positron-emission tomography (PET) scan. What is that?" Select the nurse's best reply. a. "PET uses a magnetic field and gamma waves to identify problems areas in the brain. Does your teenager have any metal implants?" b. "It's a special type of x-ray image that shows structures of the brain and whether a brain injury has ever occurred." c. "PET is a scan that passes an electrical current through the brain and shows brain wave activity. PET can help diagnose seizures." d. "PET is a special scan that shows blood flow and activity in the brain."

ANS: D The parent is seeking information about PET scans. It is important to use terms the parent can understand. The correct option is the only reply that provides factual information relevant to PET scans. The incorrect responses describe magnetic resonance imaging (MRI), computed tomographic (CT) scans, and electroencephalography (EEG).

7. A nurse assessing a patient with a somatic system disorder is most likely to note that the patient: a. Readily sees a relationship between symptoms and interpersonal conflicts. b. Rarely derives personal benefit from the symptoms. c. Has little difficulty communicating emotional needs. d. Has altered comfort and activity needs.

ANS: D The patient frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain). In addition, hygiene, safety, and security needs may also be compromised. The patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients with somatic system disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others.

23. A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan? a. No risk b. Low level c. Moderate level d. High level

ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue.

31. A patient with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D The patient is describing phenomena that indicate personal boundary difficulties. The nurse should maintain an appropriate social distance and not touch the patient, because the patient is anxious about the inability to maintain ego boundaries and merging with or being swallowed by the environment. Physical closeness or touch could precipitate panic.

21. A nurse sits with a patient diagnosed with disorganized schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The patient is likely laughing in response to inner stimuli such as hallucinations or fantasy. Focusing on the hallucinatory clue (i.e., the patient's laughter) and then eliciting the patient's observation is best. The incorrect options are less useful in eliciting a response; no joke may be involved, "Why" questions are difficult to answer, and the patient is probably not focusing on what the nurse has said in the first place.

32. An adult in the emergency department states, "I feel restless. Everything I look at wavers. Sometimes I'm outside my body looking at myself. I hear colors. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a(n): a. schizophrenic episode b. cocaine overdose c. phencyclidine (PCP) intoxication d. D-lysergic acid diethylamide (LSD) ingestion

ANS: D The patient who has ingested LSD 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. PCP use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

5. A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D The patient's history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

24. A patient with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.

24. A patient with severe anxiety suddenly begins running and shouting, "I'm going to explode!" The nurse should: a. Ask, "I'm not sure what you mean. Give me an example." b. Chase after the patient, and give instructions to stop running. c. Capture the patient in a basket-hold to increase feelings of control. d. Assemble several staff members and state, "We will help you regain control."

ANS: D The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly.

3. A 5-year-old child with attention deficit hyperactivity disorder (ADHD) bounces out of a chair in the waiting room, runs across the room, and begins to slap another child. What is the nurse's best action? a. Call for emergency assistance from another staff member. b. Instruct the parents to take the child home immediately. c. Direct this child to stop, and then comfort the other child. d. Take the child into another room with toys to act out feelings.

ANS: D The use of play to express feelings is appropriate; the cognitive and language abilities of the child may require the acting out of feelings if verbal expression is limited. The remaining options provide no outlet for feelings or opportunity to develop coping skills.

22. A patient with dementia no longer recognizes family members. The family asks how long it will be before their family member recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist family members to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two of the incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in patients with dementia.

15. Withdrawn patients with schizophrenia: a. Universally fear sexual involvement with therapists. b. Are socially disabled by the positive symptoms of schizophrenia. c. Exhibit a high degree of hostility as evidenced by rejecting behavior. d. Avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. No evidence suggests that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is not considered true that withdrawn patients with schizophrenia are socially disabled by the positive symptoms of schizophrenia or exhibit a high degree of hostility by demonstrating rejecting behavior.

3. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the bugs off me." What is the nurse's best response? a. "There are no bugs on your legs. Your imagination is playing tricks on you." b. "Try to relax. The crawling sensation will go away sooner if you can relax." c. "Don't worry, I will have someone stay here and brush off the bugs for you." d. "I don't see any bugs, but I know you are frightened so I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not emotionally support the patient. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, "You must bathe daily." d. firmly and neutrally assist the patient with showering.

ANS: D When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

2. The spouse of a patient with schizophrenia asks, "Which neurotransmitters are more active when a person has schizophrenia?" The nurse should state, "The current thinking is that the thought disturbances are related to increased activity of: (Select all that apply.) a. GABA." b. substance P." c. histamine." d. dopamine." e. norepinephrine."

ANS: D, E Dopamine plays a role in the integration of thoughts and emotions, and excess dopamine is implicated in the thought disturbances of schizophrenia. Increased activity of norepinephrine also occurs. Substance P is most related to the pain experience. Histamine decrease is associated with depression. Increased GABA is associated with anxiety reduction.

2. Which action by a psychiatric nurse best supports patients' rights to be treated with dignity and respect? a. Consistently addressing each patient by title and surname. b. Strongly encouraging a patient to participate in the unit milieu. c. Discussing a patient's condition with another health care provider in the elevator. d. Informing a treatment team that a patient is too drowsy to participate in care planning.

ANS: A A simple way of showing respect is to address the patient by title and surname rather than assuming that the patient would wish to be called by his or her first name. Discussing a patient's condition with a health care provider in the elevator violates confidentiality. Informing a treatment team that the patient is too drowsy to participate in care planning violates patient autonomy. Encouraging a patient to participate in the unit milieu exemplifies beneficence and fidelity.

13. A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

19. An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

ANS: A Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

19. An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

17. A patient being treated in an alcohol rehabilitation unit reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old child before I was admitted." Based on state and federal law, the best action for the nurse to take is to: a. anonymously report the abuse by telephone to the local child abuse hotline. b. reply, "I'm glad you feel comfortable talking to me about it." c. respect nurse-patient relationship of confidentiality. d. file a written report on the agency letterhead.

ANS: A Laws regarding reporting child abuse discovered by a professional during a suspected abuser's alcohol or drug treatment differ by state. Federal law supersedes state law and prohibits disclosure without a court order except in instances in which the report can be made anonymously or without identifying the abuser as a patient in an alcohol or drug treatment facility. Anonymously reporting the abuse by telephone to the local child abuse hotline meets federal criteria. Respecting nurse-patient confidentiality and replying, "I'm glad you feel comfortable talking to me about it" do not accomplish reporting. Filing a written report on agency letterhead violates federal law.

10. Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which statement about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to the professional standards of nursing care. b. Agency policies are the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

ANS: A Nurses are professionally bound to uphold the American Nurses Association (ANA) standards of practice, regardless of lesser standards established by a health care agency or state. Conversely, if the agency standards are higher than the ANA standards of practice, the agency standards must be upheld. The courts may seek to establish the standard of care through the use of expert witnesses when the issue is clouded.

18. An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

ANS: A Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

9. A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot injection) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop! I don't want to take that medicine anymore. I hate the side effects." Select the nurse's best initial action. a. Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." b. Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about skipping next month's dose." c. Proceed with the injection but explain to the patient that other medications are available that may help reduce the unpleasant side effects. d. Notify other staff members to report to the room for a show of force and proceed with the injection, using restraint if necessary.

ANS: A Patients with mental illness retain their civil rights unless clear, cogent, and convincing evidence of dangerousness exists. The patient in this situation presents no evidence of being dangerous. The nurse, an as advocate and educator, should seek more information about the patient's decision and should not force the medication.

5. 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.

ANS: A 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 nontherapeutic.

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

ANS: A Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

9. An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

ANS: A The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

16. A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

ANS: A The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

20. An adult has cared for a debilitated parent for 10 years. The parent's condition has recently declined, and the health care provider has recommended placement in a skilled care 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. maintaining the ability to identify situational supports in the community c. relying on the assistance from role models within the person's culture d. mobilizing automatic relief behaviors by the person

ANS: A 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 involves 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 is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

20. A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

ANS: A The patient's words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

15. The family of a patient whose insurance will not pay for continuing hospitalization considers transferring the patient to a public psychiatric hospital. The family expresses concern that the patient will "never get any treatment." Which reply by the nurse would be most helpful? a. "Under the law, treatment must be provided. Hospitalization without treatment violates patients' rights." b. "That's a justifiable concern because the right to treatment extends only to the provision of food, shelter, and safety." c. "Much will depend on other patients because the right to treatment for a psychotic patient takes precedence over the right to treatment of a patient who is stable." d. "All patients in public hospitals have the right to choose both a primary therapist and a primary nurse."

ANS: A The right to medical and psychiatric treatment was conferred on all patients hospitalized in public mental hospitals with the enactment of the federal Hospitalization of Mentally Ill Act in 1964. Stating that the concern is justifiable supports the family's erroneous belief. The provisions mentioned in the third and fourth options are not part of this or any other statute governing psychiatric care.

16. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase

ANS: A The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term, or anger phase.

10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

1. A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement 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 so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

ANS: B 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 the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

14. A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge against medical advice so I can leave now." What is the nurse's best initial response? a. "I can't give you those forms without your health care provider's knowledge." b. "I will get them for you, but let's talk about your decision to leave treatment." c. "Since you signed your consent for treatment, you may leave if you desire." d. "I'll get the forms for you right now and bring them to your room."

ANS: B A patient who has been voluntarily admitted as a psychiatric inpatient has the right to demand and obtain release in most states. However, as a patient advocate, the nurse is responsible for weighing factors related to the patient's wishes and best interests. By asking for information, the nurse may be able to help the patient reconsider the decision. The statement that discharge forms cannot be given without the health care provider's knowledge is not true. Facilitating discharge without consent is not in the patient's best interest before exploring the reason for the request.

27. Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

ANS: D Although each of the individuals mentioned experiences 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 victims of trauma.

18. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

4. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the 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

ANS: B 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.

21. After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse, "Please document the administration of the medication I forgot to do. My password is alpha1." The nurse should: a. fulfill the request. b. refer the matter to the charge nurse to resolve. c. access the record and document the information. d. report the request to the patient's health care provider.

ANS: B At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patient's health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem.

7. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

ANS: B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

5. A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

ANS: B In this situation, the nurse should consider the possibility that the patient is a victim of domestic violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

14. Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

ANS: B Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

14. Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

ANS: B Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary intervention.

15. After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

ANS: B Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

7. A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

9. A woman says, "I can't take it 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." If this person's immediate family is unable to provide sufficient situational 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 must be strong. Don't let this crisis overwhelm you." d. foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of situational supports should continue. Although 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 nontherapeutic.

1. A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

ANS: B The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

19. 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." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

ANS: B The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she "cannot think clearly."

17. A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

6. A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

ANS: B The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for domestic violence.

20. A patient with paranoid schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church. The psychiatrist notifies the minister. The psychiatrist has: a. released information without proper authorization. b. demonstrated the duty to warn and protect. c. violated the patient's confidentiality. d. avoided charges of malpractice.

ANS: B The duty of a health care professional is to warn or notify an intended victim after a threat of harm has been made. Informing a potential victim of a threat is a legal responsibility of the health care professional and not considered a violation of confidentiality.

7. A woman says, "I can't take it 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 type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

ANS: C 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.

8. A patient should be considered for involuntary commitment for psychiatric care when he or she: a. is noncompliant with the treatment regimen. b. sold sells and distributes illegal drugs. c. threatens to harm self and others. d. fraudulently files for bankruptcy.

ANS: C Involuntary commitment protects patients who are dangerous to themselves or others and cannot care for their own basic needs. Involuntary commitment also protects other individuals in society. The behaviors described in the other options are not sufficient to require involuntary hospitalization.

16. After celebrating a 40th 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

ANS: C 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. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

11. A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

ANS: C Obtaining the victim's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

3. Two hospitalized patients fight when they are in the same room. During a team meeting, a nurse asserts that safety is of paramount importance and therefore the treatment plans should call for both patients to be secluded to prevent them from injuring each other. This assertion: a. reveals that the nurse values the principle of justice. b. reinforces the autonomy of the two patients. c. violates the civil rights of the two patients. d. represents the intentional tort of battery.

ANS: C Patients have a right to treatment in the least restrictive setting. Less restrictive measures should be tried first. Unnecessary seclusion may result in a charge of false imprisonment. Seclusion removes the patient's autonomy. The principle by which the nurse is motivated is beneficence, not justice. The tort represented is false imprisonment, not battery.

17. An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: C The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

22. When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might refuse to have evidence collected or to involve law enforcement.

14. An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

26. At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to 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 a 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.

ANS: C 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 on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient's need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs.

12. A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.

ANS: C The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

12. An adult tells the nurse, "I can't take it 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 told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

ANS: C This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

16. Which individual with a mental illness may need emergency or involuntary hospitalization for mental illness? The individual who: a. resumes using heroin while still taking methadone. b. reports hearing angels playing harps during thunderstorms. c. throws a heavy plate at a waiter at the direction of command hallucinations. d. does not show up for an outpatient appointment with the mental health nurse.

ANS: C Throwing a heavy plate is likely to harm the waiter and is evidence of being dangerous to others. This behavior meets the criteria for emergency or involuntary hospitalization for mental illness. The behaviors in the other options evidence mental illness but not dangerousness.

5. Which scenario is an example of a tort? a. The primary nurse does not complete the plan of care for a patient within 24 hours of the patient's admission. b. An advanced practice nurse recommends that a patient who is dangerous to self and others be voluntarily hospitalized. c. A patient's admission status is changed from involuntary to voluntary after the patient's hallucinations subside. d. A nurse gives an as-needed dose of an antipsychotic drug to a patient to prevent violent acting-out because a unit is short staffed.

ANS: D A tort is a civil wrong against a person that violates his or her rights. Giving unnecessary medication for the convenience of staff members controls behavior in a manner similar to secluding a patient; thus false imprisonment is a possible charge. The other options do not exemplify torts.

1. A psychiatric nurse best implements the ethical principle of autonomy when he or she: a. intervenes when a self-mutilating patient attempts to harm self. b. stays with a patient who is demonstrating a high level of anxiety. c. suggests that two patients who are fighting be restricted to the unit. d. explores alternative solutions with a patient, who then makes a choice.

ANS: D Autonomy is the right to self-determination, that is, to make one's own decisions. When the nurse explores alternatives with the patient, the patient is better equipped to make an informed, autonomous decision. Staying with a highly anxious patient or intervening with a self-mutilating patient demonstrates beneficence and fidelity. Suggesting that two fighting patients be restricted to the unit demonstrates the principles of fidelity and justice.

13. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response. a. "You're right. Federal law requires me to keep that information private." b. "Those kinds of thoughts will make your hospitalization longer." c. "You really should share this thought with your psychiatrist." d. "I am obligated to share information with the treatment team."

ANS: D Breach of nurse-patient confidentiality does not pose a legal dilemma for nurses in these circumstances because a team approach to the delivery of psychiatric care presumes communication of patient information to other staff members to develop treatment plans and outcome criteria. The patient should know that the team may have to warn the father of the risk for harm.

24. A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the 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.

ANS: D 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 helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

8. A woman says, "I can't take it 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. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by, "I can't take it anymore!"

ANS: D 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.

21. A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

19. A nurse cares for an older adult patient admitted for the treatment of depression. The health care provider prescribes an antidepressant medication, but the dose is more than the usual adult dose. The nurse should: a. implement the order. b. consult a drug reference. c. give the usual geriatric dosage. d. hold the medication and consult the health care provider.

ANS: D The dose of an antidepressant medication for older adult patients is often less than the usual adult dose. The nurse should withhold the medication and consult the health care provider who wrote the order. The nurse's duty is to intervene and protect the patient. Consulting a drug reference is unnecessary because the nurse already knows the dose is excessive. Implementing the order is negligent. Giving the usual geriatric dose would be wrong; a nurse without prescriptive privileges cannot change the dose.

18. The spouse of a patient who has delusions asks the nurse, "Are there any circumstances under which the treatment team is justified in violating the patient's right to confidentiality?" The nurse must reply that confidentiality may be breached: a. under no circumstances. b. at the discretion of the psychiatrist. c. when questions are asked by law enforcement. d. if the patient threatens the life of another person.

ANS: D The duty to warn a person whose life has been threatened by a patient under psychiatric treatment overrides the patient's right to confidentiality. The right to confidentiality is not suspended at the discretion of the therapist or for legal investigations.

6. An adult seeks counseling after the spouse is 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?"

ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options are important but not the highest priority.

10. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

4. In a team meeting a nurse says, "I'm concerned whether we are behaving ethically by using restraint to prevent one patient from self-mutilation while the care plan for another patient who has also self-mutilated calls for one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

ANS: D The nurse is concerned about justice, that is, the fair treatment with the least restrictive methods for both patients. Beneficence means promoting the good of others. Autonomy is the right to make one's own decisions. Fidelity is the observance of loyalty and commitment to the patient.

4. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: D The patient's statements reflect the use of the ego defense mechanism denial. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.

12. An example of a breach of a patient's right to privacy occurs when a nurse: a. asks a family to share information about a patient's prehospitalization behavior. b. discusses the patient's history with other staff members during care planning. c. documents the patient's daily behaviors during hospitalization. d. releases information to the patient's employer without consent.

ANS: D The release of information without patient authorization violates the patient's right to privacy. The other options are acceptable nursing practices.