MH Exam 4
People living with bulimia nervosa tend to be:
Average weight People with bulimia tend to be average or slightly overweight
Which nursing intervention is the priority when caring for a child diagnosed with conduct disorder?
Recognize escalating aggressive behaviors and intervene before violence occurs. The client's behaviors create risk of other-directed violence. The nurse's priority is safety.
A patient tells the nurse, "I don't like you, you look like my grandmother." This is an example of what concept?
Transference The client is demonstrating negative transference. This client has negative thoughts toward the nurse.
Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply?
"Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone." Clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone.
The nurse tells the parents of an adolescent diagnosed with anorexia nervosa, "The social worker will be contacting you to schedule a family meeting." One of the client's parents states, "Why is that necessary? Our child is the one who needs treatment." Which response by the nurse is best?
"Family intervention and support are important in managing eating disorders." Family meetings focus on the needs of the client and their family. The nurse should educate the family on the importance of family involvement and support in the treatment of anorexia nervosa. Although conflicts can be identified during a family meeting, resolution of conflicts requires family therapy beyond the inpatient setting.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how the use of alcohol affects the client's psychosocial behaviors?
"Has alcohol use affected your performance at work?" Inquiring about work performance is appropriate to include in a psychosocial assessment related to substance use disorder. Understanding if the client has any other mental health diagnosis aides in the planning of care but is not specifically psychosocial. Understanding type doesn't address the psychosocial behavior of the client.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
"I have heard that abusers think of themselves as very important and have high self-esteem" Victimizers typically have low self-esteem and diminished feelings of self-worth. They may show a different type of personality to the community than the one shown to the partner. They keep their partners isolated from others and this potentiates the cycle of abuse.
A child has been diagnosed with autism spectrum disorder (ASD). The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate?
"Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." ASD is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. ASD occurs in approximately 6 per 1000 children and is about four times more likely to occur in boys.
A client is pacing the hall near the nurse's station, swearing loudly. An appropriate initial intervention for the nurse would be to address the client by name and say:
"You seem upset. Would you like to tell me about it?" This response is the most therapeutic. You should never use the why when capable of avoiding it.
Of the following populations, which would Tourette's be most common in?
6-7 year old boys Onset may be as early as 2 years but occurs most commonly around age 6 or 7. The disorder is more common in boys than in girls.
You are the night nurse who has just gotten report on the following patients. Prioritize which of the patients you would see first.
70 year old male who is a post-surgical hip fracture with a history of dementia This patient is at high risk for falls AEB his history of dementia and recent surgery.
A nurse is assessing a child and suspects child abuse. Which assessment finding support the nurse's assumption?
A circular burn on the child's arm A circular burn is not a normal finding and can indicate a burn from a cigarette or other smoked substance. Bruising is an expected finding if a child is active these will be in consistent areas that would indicate falls during play. Children that are active may present with bumps on head from falls. A child that has been abused may rather than acting out be subdued and fearful.
The nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first?
A client diagnosed with Conduct Disorder who is verbally abusing a peer in the milieu A client diagnosed with Conduct Disorder who is verbally abusing a peer in the milieu creates risk for injury to others.
The clearest indication of success in behavior modification related to eating disorders would be...
A client showing and demonstrating that they have perceptions of control over their life and treatments For a successful behavior modification, the client must perceive that they are in control of the treatment, recognize options and goals, in accordance with their healthcare providers.
A nurse is reviewing the medical histories of four clients. Which of the following clients will be most likely to develop extrapyramidal symptoms from medication therapy?
A client with schizophrenia taking a first-generation antipsychotic A client who has schizophrenia and is taking first generation antipsychotic medication can develop extrapyramidal manifestations, such as acute dystonia, Parkinsonism, akathisia, and tardive dyskinesia. First generation = typical antipsychotics = more potent = have more side effects
A group of nurses is discussing how food is used in their families and the effects this might have on their ability to work with clients diagnosed with eating disorders. Which nurse is most likely to be most effective with these clients?
A nurse that refuses to engage in power struggles over food The nurse who refuses to engage in power struggles is likely to be the most effective when working with clients with eating disorders. The nurse understands that the client's issues are related to control rather than food consumption. Source(s): ATI, textbook, lecture
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
A private room in a quiet location that can easily be monitored A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.
A nurse is caring for a client who is cognitively impaired. Which of the following rooms will provide a therapeutic environment for this client?
A room containing personal belongings nearby without contrabands A room that contains several of the client's personal belongings assists in maintaining personal identity and provides a therapeutic environment. This will aide in the therapeutic care and minimize anxiety and distress in the client. This client should be monitored but a lot of added stimuli may cause the client to become distressed and exhibit unwanted behaviors.
A nurse assessing a client with post-traumatic stress disorder (PTSD) would expect the client to report which finding?
Fatigue Clients with PTSD will have fatigue from loss of sleep. These clients regularly have flashbacks and nightmares and as such they will not sleep or report not sleeping well. These clients tend to have a loss of appetite and do not regularly take advantage of anyone else. Source(s): textbook, and lecture
A nurse is planning care for a client who has antisocial personality disorder. Which of the following actions should the nurse plan to take?
Set limits to prevent exploitation of other clients. A trademark feature of APD is exploitation of others. These clients must have clear boundaries set. These clients are more in tune with appropriate behavior and are not as likely to be overly dramatic.
A nurse is caring for a client who has a new prescription for risperidone. Which of the following rating scales should the nurse complete prior to administering the first dose of risperidone?
Abnormal Involuntary Movement Scale Risperidone, an antipsychotic, can cause tardive dyskinesia, involuntary movements that may include the tongue, lips, and face. The nurse should perform the AIMS assessment prior to initiating treatment with risperidone and then at regularly scheduled intervals thereafter.
A clearly underweight client presents constant descriptions of distorted body images and denies that they ever binge eat. You can assume that the client is suffering from:
Anorexia Nervosa The distortion in body image by clients diagnosed with anorexia nervosa is manifested by thoughts that they are fat when they are obviously underweight or even emaciated.
A nurse is educating staff on personality disorders. Which statement by the staff indicated understanding?
Antisocial personality disorder can start as conduct disorder APD can start as conduct disorder while in childhood. The different disorders overlap and can be difficult for even prescribers to identify. These disorders have signs that you look for and will create a plan of care based on what behaviors and thoughts the client has.
Symptoms of amphetamine withdrawal include:
Anxiety, depressed mood, irritability, and craving for the substance The client with amphetamine withdrawal may experience anxiety, depressed mood, irritability, craving for the substance, fatigue, insomnia or hypersomnia, psychomotor agitation, paranoid and suicidal ideation.
Which of the following is an FDA approved medication for the pharmacological intervention of Autism Spectrum Disorder (ASD)?
Aripiprazole The two medications for ASD approved by the FDA are Risperidone and Aripiprazole. These medications target aggression, self injury, temper tantrums, and quick changes in mood.
A nurse is planning care for a client who has a diagnosed anxiety disorder. Which of the following intervention should the nurse implement to promote occupational functioning?
Assist the client in identifying triggers This client may want to use their spirituality in aiding with relaxation, but the identification of spirituality will not in itself reduce the anxiety. This client needs to be able to identify stressors. If the client can identify some things that cause stress this client can learn to function day to day.
A nurse is caring for a client who with an eating disorder. The nurse is demonstrating which of the following ethical concepts when they allow the client to refuse to drink a between meal protein and calorie supplement?
Autonomy Autonomy respects the rights of clients to refuse medication or treatment. The nurse is allowing the client to make the decision not to participate in this treatment at this time.
The most important short term goal of a client with avoidant personality disorder would be to:
State a positive personality trait The client with avoidant personality disorder has low self esteem and self worth. This client will be increasingly inhibited. The nurse should encourage and support the client and give reassurance and help them with encourage them in building their self esteem.
A nurse is admitting a 14-year-old with conduct disorder. What would the nurse anticipate finding in this assessment?
Bullying of others Conduct disorder involves bullying and mistreatment of others as well as illegal and elicit behavior. These children often engage in behavior that is coercive and criminal. These clients will escalate into adulthood and can be diagnosed later in life with cluster B personality disorders as they continue to take advantage of others.
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. This patient is at risk of what complication?
Cardiac Arrhythmia This patient presents with imbalanced nutrition related to not eating. The patient has hypokalemia which will result in changes in ECG. This client will also have bradycardia, elevated cortisol and osteopenia.
A nurse is attempting to differentiate between the symptoms of anorexia nervosa and the symptoms of bulimia. Which statement delineates the difference between these two disorders?
Clients diagnosed with anorexia nervosa experience extreme nutritional deficits, whereas clients diagnosed with bulimia nervosa do not. Bulimic clients tend to have some nutrient absorption prior to their purging however, clients with anorexia do not intake the food and thus have a lack of nutrients to their bodies.
A nurse questions the order to begin nourishing an emaciated client slowly. The prescriber explains the reason behind this choice is:
Clients may die from being nourished too quickly Nourishing the client too quickly causes an electrolyte shift and can cause death.
A 28-year-old client with body dysmorphic disorder (BDD) tells the nurse that they plan to have a surgical procedure that will affect their appearance. The nurse understands that this plan is an effort to?
Cure the imagined defect With BDD the client has a perceived defect, they will seek to alter this defect through means such as plastics procedures. These clients seek extreme measures to cure this defect that only they see.
Rank the following nursing interventions based on priority of a patient diagnosed with bulimia nervosa A) Draw Blood for CBC and CMP B) Asses for depression C) Obtain Vitals D) Perform ECG E) Teach and encourage on self-care activities
D, C, A, B, E The priority here is the ECG because patients with Bulimia nervosa are at high risk for low potassium, which can lead to ECG changes and life threatening arrythmias. Next you would obtain vitals to determine the patient's current level of hemodynamic stability which can also be affected by the client's altered electrolyte imbalance. Third, you draw blood to monitor electrolytes. Forth, depression is assessed and common amongst individuals with BN. Last you would promote and perform education for the patient for long term goals.
A patient with a substance abuse problem makes statements such as, "I don't have a problem with (substance)" or "I can quit any time I want to." The patient also does not perceive any problems related to use of the substance and is unable to admit the impact of the disease on his or her life patterns and functioning. What nursing diagnosis would you assign to this patient?
Denial Denial is defined as a "conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health" (Herdman & Kamitsuru, 2018, p. 336). The patient with substance abuse disorder may be in denial about their addiction and downplay any associated problems or impairments in social or occupational functioning related to the addiction
A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes washing their hands and completing ritualistic tasks. Which nursing intervention would best address this client's problem?
Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors. Discussing triggers will enable the client to address and deal with obsessions and compulsions. Distracting the client will increase the anxiety. Discuss the triggers to be able to assist the client in their therapeutic recovery.
The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa?
Eliminate emotional components of maladaptive eating patterns. CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings
The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa?
Eliminate emotional components of maladaptive eating patterns. CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings.
A nurse is caring for a client who has schizophrenia. The client states, "The weather channel lady loves me and she is going to quit her show to be with me!" The nurse should document that the client is experiencing which of the following types of delusions?
Erotomanic A client that is experiencing erotomania thinks that someone else loves them or that they are in love with the other party. These clients will maintain this delusion. This behavior can lead to stalking or other inappropriate actions on the part of the psychotic client.
Possible predisposing factors to Schizoid personality disorder include all of the following except :
Having overly protective parents Predisposing factors to schizoid personality disorders include possible hereditary factors and many descriptions of a cold lacking childhood.
A client taking phenelzine has a blood pressure of 210/119, a HR of 104 bpm, and diaphoresis. The nurse discovers the client has recently taken over the counter medication for allergies and a cold. The nurse recognizes this client is experiencing:
Hypertensive crisis Hypertensive crisis brought on by over the counter cold medication. Clients on MAOI should be counselled not to take any OTC medications prior to consulting their physician.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
Identify stressors that precipitate rituals This is the priority intervention when taking the nursing process approach to client care. The other interventions should be carried out after stressors are identified. The schedule should not be set until the client's stressors are identified.
An unlicensed assistive personnel (UAP) is working with clients that have diagnosis of obsessive compulsive disorder. The UAP understands the reason not to stop the carrying out of compulsions is:
If this is not done therapeutically the client will have an escalation in anxiety The clients with OCD get relief by carrying out compulsions and if this is not discontinued therapeutically it will increase anxiety and set the client back in therapy. Both the obsession and the compulsions are problems and need to be addressed properly. A UAP is part of the healthcare team and should understand the roles that each member play and that this is not a discriminatory intervention on the part of the nurse
The nurse working in an acute care psychiatric facility is working with clients that have personality disorders. The nurse knows that cluster A personality disorders (odd, eccentric) tend to exhibit what behaviors?
Indifference to social situations Cluster A trademarks are odd, eccentric and indifferent to social situations. These clients do not seek out interaction and when in social situations may not interact in an appropriate manner. They exhibit some magical thinking or paranoia and are not perceived by others positively.
A client is experiencing command hallucinations and appears to be frightened. Which of the following actions are appropriate nursing interventions?
Keep the client physically safe Validate the patient's feelings. Keep them physically safe. Determine what the hallucination is telling them to do and provide reality testing PRN.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Lower the bed The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to raise the side rails of the bed. The nurse should obtain a medical history and CIWA scale after making sure the client is safe; therefore, this is not a priority action. The nurse should administer diazepam when the client is safe and after obtaining a CIWA; therefore, this is not a priority action
Consider this comment to three different nurses by a patient diagnosed with antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as:
Manipulative The patient is demonstrating manipulation with this statement. This behavior is a hallmark of the cluster B personality disorders. This is technically defined as "splitting".
A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?
Mental status examination (MSE) The use of an MSE assists in identifying deterioration in mental status and brain damage, which are findings associated with cognitive disorders. AIMS-tardive dyskinesia, SANS- schizophrenia, Brief PHQ-depression
The following are characteristics of which Cluster B personality Disorder: Arrogance, Grandiosity, lack of empathy and sensitive to criticism
Narcissistic Personality Disorder Narcissistic Personality Disorder is a Cluster B personality Disorder with characteristics such as arrogance, grandiosity, lack of empathy and sensitive to criticism
What is the difference between conduct disorder (CD) and oppositional defiance disorder (ODD)?
ODD does not involve physical aggression ODD is present in conduct disorder; however, CD also has physical aggression, drug use and illegal activity . Neither of these disorders is only present in 1 gender. Both disorders are present in the adolescent period.
The following are all common comorbid psychiatric disorders prevalent with ADHD, except:
Obsessive Compulsive Disorder Common comorbid psychiatric disorders are prevalent with ADHD. Oppositional defiant disorder: Conduct disorder Anxiety Depression Bipolar disorder Substance use disorders
A client with anorexia nervosa is at increased risk for which of the following?
Osteopenia A client with anorexia nervosa is at risk for decreased bone density, osteoporosis and osteopenia. Osteopenia is a condition that begins as you lose bone mass and your bones get weaker. This happens when the inside of your bones become brittle from a loss of calcium.
Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are:
Perfectionist, inflexible OCP patients typically like things in a very orderly fashion and are inflexible in their ritualistic behaviors. These clients believe that the problems that they encounter are not their fault, but the fault of others. These clients are not impulsive as they like to have things set up and planned out.
A client is diagnosed with PTSD. Which treatment modality exposes the client to repeated and prolonged mental recounting of the traumatic event?
Prolonged exposure therapy Prolonged exposure therapy is a type of behavioral therapy similar to implosion therapy or flooding. It can be conducted in an imagined or real (in vivo) situation. In the imagined situation, the individual is exposed to repeated and prolonged mental recounting of the traumatic experience. In vivo exposure involves systematic confrontation, within safe limits, of trauma-related situations that are feared and avoided. This intense emotional processing of the traumatic event serves to neutralize the memories so that they no longer result in anxious arousal or escape and avoidance behaviors.
This is a potentially fatal complication that results in the introduction of fluids and carbohydrates for patients who are malnourished....
Refeeding syndrome Refeeding syndrome is a potentially fatal complication resulting from aggressive initiating of feedings that results in the introduction of fluids and carbohydrates for patients who are malnourished.
A nurse is assessing a 5-year-old client with autism spectrum disorder. For which of the following manifestations will the nurse assess?
Repetitive hand gestures Repetitive actions are a common feature of autism spectrum disorder. The client with autism will not be overly emotional or sedate. The client will not experience somatic illness due to autism, but GI and seizure disorders are common concurrent diagnosis.
Which of the following defense mechanisms describes the underlying cause of somatic symptom disorder?
Repression of anxiety This group of disorders is caused by avoidance and repression of feelings. The reason the client experiences symptoms is that they do not deal with their feelings and anxiety.
A nurse is performing an admission assessment for an adolescent client with a diagnosis of schizophrenia. Which of the following findings should the nurse identify as a positive symptom?
Somatic Delusions Delusions are example of a positive symptom. Anhedonia, waxy posture, and anergia are negative symptoms. Positive symptoms, which include delusions, hallucinations, disorganized thoughts, and disorganized speech; can cause you or someone you love to lose touch with reality. Negative schizophrenia refers to behaviors or emotions that are deficient or lacking in people with schizophrenia
A client prescribed sertraline asks about alternative therapies to treat the depression that she is experiencing regarding her current family situation. Which statement by the student nurse indicates a need for intervention?
St John's wort is an excellent treatment for depression St John's wort is taken by some to reduce feelings of depression, but it can interact and cause dangerous side effects with many psychotropic medications. ECT can be very effective in depression and is used after medication has been attempted and is not successful. Antidepressants may interact with many OTC medications.
Personality traits most likely to be documented regarding a patient demonstrating characteristics of a paranoid personality disorder are:
Suspicious, holds grudges PPD clients suspect others to have ulterior motives and tend to hold grudges for imagined slights. These clients do not do well in social situations and tend to avoid them. These clients are more traditionally closed off and will not be generous with others
Which finding is the nurse most likely to assess in a child diagnosed with separation anxiety disorder?
The child's mother is diagnosed with an anxiety disorder. A child whose mother is diagnosed with an anxiety disorder has a greater risk of developing an anxiety disorder. Research indicates that there is a hereditary influence in the development of separation anxiety disorder. More children with relatives who manifest anxiety problems develop anxiety disorders than those without.
The client states "I just can't fall asleep". The nurse responds, "You are having difficulty falling asleep?" Why is the nurse using the restating technique?
The nurse is allowing the client to elaborate or clear up misunderstanding Establishes priority with nursing goals and interventions related to therapeutic interaction. Using the client's words or close to is restating. This technique allows the client to be able to elaborate or clear up any miscommunications with nursing. This also gives the feedback that their concerns are being heard
After an adolescent diagnosed with attention-deficit/hyperactivity disorder (ADHD) begins methylphenidate therapy, the nurse notes that the adolescent loses 10 pounds in a 2-month period. Which is the best explanation for this weight loss?
The pharmacological action of methylphenidate causes a decrease in appetite. The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed ADHD.
A nurse is teaching a male client who has a depressive disorder about escitalopram. Which of the following information should the nurse include in the teaching?
This medication may cause an inability to orgasm Escitalopram is an SSRI. SSRIs may cause sexual dysfunction, including anorgasmia, impotence, or decreased libido. Fever and muscle rigidity are medical emergencies with this medication, this medication will take 4-6 weeks to reach full effect.
The nurse working with a client diagnosed with Bulimia Nervosa asks the client to recall a time in life when food could be consumed without purging. Which best explains the purpose of the nurse's question?
To emphasize that the client is capable of consuming food without purging The nurse is identifying the client's previous successful coping strategies. The nurse will utilize the data to develop interventions to help the client employ prior coping skills to replace maladaptive eating behaviors. This is cognitive-behavioral therapy.
Jane is a 4-year-old who wakes up screaming in her room, she is frantic, states she wants her mom who had to leave hours ago to go home. All of the therapeutic techniques may be effective except:
Turning off the lights to calm her down While working with pediatric clients it is important to be aware of anxiety. This client is experiencing fear and anxiety and the nurse must use therapeutic communication in the interaction
