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MH Exam 6

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Client Needs: Safe, Effective Care Environment 8. An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." 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

A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 28û22 | Page 23 | Page 51 (Box 28-4) TOP: Nursing Process: Diagnosis/Analysis

MULTIPLE CHOICE 1. Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543 | Page 546 TOP: Nursing Process: Implementation

neglect

A child comes into the physician's office with several infected wounds on the extremities. The nurse notes the child has poor hygiene, is malnourished, and there is dirt in the wounds. Which type of abuse does the nurse suspect?

A mother brings her 4-year-old daughter to the emergency department and states that the child has been "acting funny." The mother states, "She touches her vagina and rubs herself down there all the time and she never did that before." This behavior best supports which conclusion? a. The child has been sexually abused. b. The mother needs education in parenting skills. c. This is normal developmental behavior in a 4-year-old child. d. The child has been exposed to graphic sexual images on television.

A patient prepares for discharge from the emergency department after treatment for injuries associated with intimate partner violence. The patient plans to return home. Which action by the nurse has priority? a. Refer the patient for pastoral counseling. b. Provide the patient with contact information for the local shelter. c. Encourage the patient to file criminal charges against the perpetrator. d. Tell the patient, "I have documented your injuries and treatment thoroughly."

2. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate IDD? 1. Meeting all of the client's self-care needs to avoid injury to the client 2. Providing simple directions and praising client's independent self-care efforts 3. Avoid interfering with the client's self-care efforts in order to promote autonomy 4. Encouraging family to meet the client's self-care needs to promote bonding

ANS 2: Rationale: Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate IDD. Individuals with moderate mental retardation can perform some activities independently and may be capable of academic skill to a second-grade level.

A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: 1 Rationale: The nurse should determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships

6. A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome? 1. Neuroleptic medications 2. Anti-manic medications 3. Tricyclic antidepressant medications 4. Monoamine oxidase inhibitor medications

ANS: 1 Rationale: The nurse should recognize that neuroleptic (antipsychotic) medications are effective in the treatment of Tourette's syndrome. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy.

5. After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: 1 Rationale: The pharmacological action of Ritalin causes a decrease in appetite, which often leads to weight loss. Methylphenidate is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability.

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.

Which of the following risk factors, if noted during a family history assessment, should a nurse associate with the development of IDD? (Select all that apply.) 1. A family history of Tay-Sachs disease 2. Childhood meningococcal infection 3. Deprivation of nurturance and social contact 4. History of maternal multiple motor and verbal tics 5. A diagnosis of maternal major depressive disorder

ANS: 1, 2, 3 Rationale: The nurse should recognize a family history of Tay-Sachs disease, childhood meningococcal infections, and deprivation of nurturance and social contact as risk factors that would predispose a child to IDD. There are five major predisposing factors of IDD: hereditary factors, early alterations in embryonic development, pregnancy and perinatal factors, medical conditions acquired in infancy or childhood, and environmental influences and other mental disorders.

A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of IDD? 1. Risk for injury R/T self-mutilation 2. Altered social interaction R/T non-adherence to social convention 3. Altered verbal communication R/T delusional thinking 4. Social isolation R/T severely decreased gross motor skills

ANS: 2 Rationale: The appropriate nursing diagnosis associated with this degree of IDD is altered social interaction R/T non-adherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual developmental disorder and may also experience some limitations in speech communications.

3. A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? 1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"

ANS: 2 Rationale: The most appropriate response by the nurse is to explain to the parent that autistic spectrum disorder is believed to be caused by abnormalities in brain structure or function, not poor parenting. Autism occurs in approximately 11.3 per 1,000 children and is about 4.5 times more likely to occur in boys than girls.

A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? 1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"

7. Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother is diagnosed with an anxiety disorder. 3. The child previously had an extroverted temperament. 4. The child's mother and father have an inconsistent parenting style.

ANS: 2 Rationale: The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother is diagnosed with an anxiety disorder. 3. The child previously had an extroverted temperament. 4. The child's mother and father have an inconsistent parenting style.

8. A child has been recently diagnosed with mild IDD. What information about this diagnosis should the nurse include when teaching the child's mother? 1. Children with mild IDD need constant supervision. 2. Children with mild IDD develop academic skills up to a sixth-grade level. 3. Children with mild IDD appear different from their peers. 4. Children with mild IDD have significant sensory-motor impairment.

ANS: 2 Rationale: The nurse should inform the child's mother that children with mild IDD develop academic skills up to a sixth-grade level. Individuals with mild IDD are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

ANS: 2 Rationale: The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

Which behavioral approach should a nurse use when caring for children diagnosed with disruptive behavior disorders? 1. Involving parents in designing and implementing the treatment process 2. Reinforcing positive actions to encourage repetition of desirable behaviors 3. Providing opportunities to learn appropriate peer interactions 4. Administering psychotropic medications to improve quality of life

ANS: 2 Rationale: The nurse should reinforce positive actions to encourage repetition of desirable behaviors when caring for children diagnosed with disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

Which of the following findings should a nurse identify that would contribute to a client's development of ADHD? (Select all that apply.) 1. The client's father was a smoker. 2. The client was born 7 weeks premature. 3. The client is lactose intolerant. 4. The client has a sibling diagnosed with ADHD. 5. The client has been diagnosed with dyslexia.

ANS: 2, 4 Rationale: The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences, such as lead exposure and diet, can be linked with the development of ADHD.

A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with neuroleptic medications. 3. Hold client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.

ANS: 3 Rationale: The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.

4. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.

ANS: 3 Rationale: The most realistic client outcome for a child diagnosed with autistic spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

9. A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual developmental disorder (IDD). Which student statement indicates that further instruction is needed? 1. "These clients can work in a sheltered workshop setting." 2. "These clients can perform some personal care activities." 3. "These clients may have difficulties relating to peers." 4. "These clients can successfully complete elementary school."

ANS: 4 Rationale: The nursing student needs further instruction about moderate IDD, because individuals diagnosed with moderate IDD are capable of academic skill up to a second-grade level. Moderate IDD reflects an IQ range of 35 to 49.

7. A 78-year-old nursing home resident with hypertension and cardiac disease is usually alert and oriented. This morning, however, the resident says, "My family visited during the night. They stood by the bed and talked to me." In reality, the patient's family lives 200 miles away. The nurse should first suspect that the resident: a. may have a cognitive impairment associated with medication effects. b. may be developing Alzheimer's disease associated with advanced age. c. had a transient ischemic attack and developed sensory perceptual alterations. d. has a previously unidentified alcohol dependency and is beginning alcohol withdrawal delirium.

ANS: A A resident taking medications is at high risk for becoming confused because of medication side effects, drug interactions, and delayed excretion. The nurse should report the event and continue to assess for cognitive impairment. Symptoms of dementia develop slowly but persist over time. Alcohol dependency and withdrawal are not the nurse's first suspicion in this scenario.

7. A person with serious and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices

ANS: A Basic psychosocial needs do not change because a person is homeless. The nurse's initial priority should be establishing rapport. Once a trusting relationship is established, then the nurse can pursue other interventions.

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty relating to others b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities

ANS: A Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases.

9. A homeless patient with serious and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication, and housing for the patient was obtained in a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."

ANS: A Evaluation of a patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes an improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.

6. A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers "yes" to which question? a. "Would you say your mood is often low?" b. "Are you having any trouble with your memory?" c. "Have you noticed an increase in your alcohol use?" d. "Do you often experience moderate-to-severe pain?"

ANS: A Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need to assess further for other symptoms of depression. The other options do not focus on mood.

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.

2. A community mental health nurse plans an educational program for the staff members of a home health agency that specializes in the care of older adults. A topic of high priority should be: a. identifying clinical depression in older adults. b. providing cost-effective foot care for older adults. c. identifying nutritional deficiencies in older adults. d. psychosocial stimulation for those who live alone.

ANS: A The topic of greatest immediacy is the identification of clinical depression in older adults. Home health staff members are better versed in the physical aspects of care and less knowledgeable about mental health topics. Statistics show that older adult patients with mental health problems are less likely than young adults to be diagnosed accurately. This is especially true for those with depression and anxiety, both of which are likely to be misinterpreted as normal aging. Undiagnosed and untreated depression and anxiety result in unnecessary suffering. The other options are of lesser importance.

2. Severe and persistent mental illness is characterized as a: a. mental illness of longer than 2 weeks' duration b. major chronic mental illness marked by significant functional impairments c. mental illness accompanied by physical impairment and severe social problems d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities

ANS: B "Severe and persistent mental illness" has replaced the phrase "chronic mental illness." Global impairments in function are evident, including social skills. Physical impairments may be present. Severe mental illness can be treated, but remissions and exacerbations are part of the course of the illness.

1. A student nurse visiting a senior center tells the instructor, "It's so depressing to see all these old people. They are so weak and frail. They are probably all senile." The student is expressing: a. reality. b. ageism. c. empathy. d. advocacy.

ANS: B Ageism is defined as a bias against older people because of their age. None of the other options can be identified from the ideas expressed by the student.

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.

4. A 75-year-old patient comes to the clinic reporting frequent headaches. After an introduction at the beginning of the interview, the nurse should: a. initiate a neurologic assessment. b. ask if the patient can hear clearly as the nurse speaks. c. suggest that the patient lie down in a darkened room for a few minutes. d. administer medication to relieve the patient's pain before performing the assessment.

ANS: B Before proceeding, the nurse should assess the patient's ability to hear questions. Impaired hearing could lead to inaccurate answers. The nurse should not administer medication (an intervention) until after the assessment is complete.

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.

6. A patient living independently has command hallucinations to report terrorism to the Federal Bureau of Investigation (FBI) and to shout warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, "You can't come back here. You cause too much trouble." What problem is the patient experiencing? a. Grief b. Stigma c. Homelessness d. Lack of insurance parity

ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data also do not suggest that the patient is actually homeless. Insurance parity is not relevant to this scenario.

3. Which is the best comment for a nurse to use when beginning an interview with an older adult patient? a. "Hello, [call patient by first name]. I am going to ask you some questions to get to know you better." b. "Hello. My name is [nurse's name]. I am a nurse. Please tell me how you would like to be addressed by the staff." c. "I am going to ask you some questions about yourself. I would like to call you by your first name if you don't mind." d. "You look as though you are comfortable and ready to participate in an admission interview. Shall we get started?"

ANS: B This opening identifies the nurse's role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name, but should not assume a patient wants to be called by his or her first name. The nurse should always introduce him- or herself.

*A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to:* a. promote integration of self-concept. b. provide inpatient treatment for the child. c. reduce loneliness and increase self-esteem. d. improve language and communication skills.

ANS: C Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

*Which behavior indicates that the treatment plan for a child diagnosed with an 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 an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

1. Health maintenance and promotion efforts for patients with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections b. monitoring of self-care abilities c. screening for cancer, hypertension, and diabetes d. determination of adequacy of a patient's support system

ANS: C Individuals with severe mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patients with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patient's support system is not usually considered part of health promotion and maintenance.

4. Which nursing diagnosis is likely to apply to an individual with severe and persistent mental illness who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

ANS: C Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA) International diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless.

1. A nurse working with a person whose spouse recently died uses cheer and humor to lift the person's spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct? a. The nurse's technique was effective. b. Use of humor should be added to the plan of care. c. This approach may prove useful in other, similar situations. d. The nurse needs supervision; the communication technique was not appropriate.

ANS: D Clinical supervision will review the nurse's actions and thoughts and help the nurse arrive at a more therapeutic approach. Attempts at cheering up a patient who is depressed serve only to emphasize the disparity between the patient's mood and that of others. Active listening should be the technique used by the nurse. The incorrect options suggest the approach is therapeutic when it is not.

3. After the death of a spouse, an adult repeatedly says, "I should have made him go to the doctor when he said he didn't feel well." This individual is experiencing: a. preoccupation with the image of the deceased. b. sensations of somatic distress. c. anger. d. guilt.

ANS: D Guilt is evident by the bereaved person's self-reproach. Preoccupation refers to dwelling on images of the deceased. Somatic distress would involve bodily symptoms. Anger is not evident from data given in this scenario.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for: a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder.

ANS: D Excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

3. A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, "That girl looked like she was 19 years old." Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization

ANS: D Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is justifying the molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one's behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings.

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.

A child diagnosed with attention deficit hyperactivity disorder had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child: a. has an improved ability to identify anxiety and use self-control strategies. b. has increased expressiveness in communication with others. c. shows increased responsiveness to authority figures. d. engages in cooperative play with other children.

ANS: D The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

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.

economic abuse

An elderly patient pays the bills because the patient fears that his or her family will make him or her live elsewhere if the patient doesn't "help out." The nurse assesses this as what?

An individual with substance abuse problems is more likely to behave as a perpetrator in family violence. How do alcohol and other drugs trigger this behavior in an individual? a. The person learns and uses new social skills. b. The person has a desire to be socially accepted. c. The person develops a disregard for social rules. d. The person develops feelings of worthlessness.

Client Needs: Psychosocial Integrity 3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding 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

B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 (Table 28-3) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 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 enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

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 feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 6. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 543 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 2. An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual c. Emotional b. Physical d. Economic

C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 538-539 TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 7. Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain. c. bruises on extremities. b. repeated middle ear infections. d. diarrhea.

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, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 9. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships c. Socialization skills b. Work responsibilities d. Physical injuries

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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

The nurse is counseling a victim of family violence. What key idea does the nurse need to emphasize to the victim during crisis intervention? a. An abuser can be changed when the abuser learns coping skills. b. Skills to manage a stressful situation can help in preventing a crisis. c. People can turn to support groups to manage a stressful situation. d. People have a right to live without fear of violence, physical harm, or assault.

The nurse is developing a plan of care for a person who is hostile, demonstrates poor coping skills, and is addicted to substances. What would be an appropriate nursing diagnosis for this person? a. Anxiety and hopelessness b. Dysfunctional family process c. Ineffective individual coping d. Ineffective role performance

Which factor is of least importance as a victim of spousal abuse constructs a safety plan? a. Where the victim will go to be safe b. How the victim will arrange for transportation c. How the victim will explain the decision to leave d. What the victim will need to take when he or she leaves

Which of the following is least likely to predispose a child to Tourette's Disorder? a. absence of parental bonding b. family history of the disorder c. abnormalities of brain neurotransmitters d. structural abnormalities of the brain

Which of the following nursing diagnoses would be considered the priority in planning care for the child with autism spectrum disorder? a. Risk for self-mutilation evidenced by banging head against wall b. Impaired social interaction evidenced by unresponsiveness to people c. Impaired verbal communication evidenced by absence of verbal expression d. Disturbed personal identity evidenced by inability to differentiate self from others

3. A physician informed an adult of the results of diagnostic tests that showed lung cancer. Later in the day the patient says to the nurse, "My doctor said I have breathing problems, right?" Which nursing diagnosis is applicable? a. Denial related to acceptance of new diagnosis b. Chronic sorrow related to unresolved life conflicts c. Situational low self-esteem related to stress of new diagnosis d. Acute confusion related to metastatic changes to cerebral function

a. Denial related to acceptance of new diagnosis

1. Sixteen years ago a toddler died in a tragic accident. Once a year, the parents place flowers at the accident site. How would the nurse characterize the parents' behavior? a. Mourning b. Bereavement c. Complicated grief d. Disenfranchised grief

a. Mourning

The child with ADHD has a nursing diagnosis of impaired social interaction. Which of the following nursing interventions are appropriate for this child? select all that apply. a. Socially isolate the child when interactions with others are inappropriate b. set limits with consequences on inappropriate behaviors c. provide rewards for appropriate behaviors d. provide group situations for the child

b, c, d

In an effort to help the child with mild to moderate intellectual disability develop satisfying relationships with others, which of the following nursing interventions is most appropriate? a. interpret the child's behavior for others b. set limits on behavior that is socially inappropriate c. Allow the child to behave spontaneously, for he or she has no concept of right or wrong d. this child is not capable of forming social relationships

Which of the following activities would be most appropriate for the child with ADHD? a. monopoly b. volleyball c. pool d. checkers

Which of the following groups is most commonly used for drug management of the child with ADHD? a. CNS depressants (e.g. diazepam [Valium]) b. CNS stimulants (e.g. methylphenidate [Ritalin]) c. Anticonvulsants (e.g. phenytoin [Dilantin]) d. Major tranquilizers (e.g. haloperidol [Haldol])

5. A nurse who has worked for a community hospice organization for 8 years says, "My patients and their families experience overwhelming suffering. No matter how much I do, it's never enough." Which problem should the nursing supervisor suspect? a. The nurse is experiencing spiritual distress. b. The nurse is at risk for burnout and compassion fatigue. c. The nurse is not receiving adequate recognition from others. d. The nurse is at risk for overhelping, which creates dependency.

b. The nurse is at risk for burnout and compassion fatigue.

The nursing history and assessment of an adolescent with a conduct disorder might reveal of the following behaviors except: a. manipulation of others for fulfillment of own desires b. chronic violation of rules C. feelings of guilt associated with the exploitation of others d. inability to form close peer relationships

The child with autism spectrum disorder has difficulty with trust. With this in mind, which of the following nursing actions would be the most appropriate? a. Encourage all the staff to hold the child as often as possible, conveying trust through touch b. Assign a different staff member each day so child will learn that everyone can be trusted c. Assign same staff person as often as possible to promote feelings of security and trust d. Avoid eye contact, because this is extremely uncomfortable for the child and may even discourage trust

Certain family dynamics often predispose adolescents to the development of conduct disorder. Which of the following patterns is thought to be a contributing factor? a. Parents who are overprotective b. Parents who have high expectations for their children c. Parents who consistently set limits on their children's behavior d. parents who are alcohol dependent

4. A nurse leads a bereavement group. Which participant's comment best demonstrates that the work of grief has been successfully completed? a. "Our time together was too short. I only wish we had done more things together." b. "I know our life together was a blessing that I did not deserve. I wish I had said 'I love you' more often." c. "Other people knew my loved one as a good and helpful person. I hope people see me in the same way." d. "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

d. "Our best vacations always involved water. When I see pictures of the ocean, those memories come flooding in."

2. A recently widowed adult says, "I've been calling my neighbors often but they act like they don't want to talk to me. I just need to talk about it, you know?" What is the nurse's best action? a. Say to the person, "You may call me anytime you need to talk." b. Ask the person, "What do you mean by 'I just need to talk about it'?" c. Educate the person about the importance of finding alternative activities. d. Tell the person the location and time of a local bereavement support group.

d. Tell the person the location and time of a local bereavement support group.

Which factor presents the highest risk for a child to develop a psychiatric disorder? a. Having an uncle with schizophrenia b. Being the oldest child in a family c. Living with an alcoholic parent d. Being an only child

ANS: C Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Being in a middle-income family and being the oldest child do not represent psychosocial adversity. Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family offers a greater risk.

Client Needs: Psychosocial Integrity 5. The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused. c. have eating disorders. b. are attention seeking. d. are developmentally delayed.

A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 533 (Box 28-1) TOP: Nursing Process: Assessment

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.

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.

4. The older patient is discussing chronic pain and asks the primary care provider for a prescription. Which medication should the nurse anticipate being ordered rather than an opioid? a. Gabapentin b. Acetaminophen c. Morphine d. Fentanyl

a. Gabapentin

Client Needs: Safe, Effective Care Environment 11. A patient tells the nurse, "My husband lost his job. He's abusive only 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 c. Abuse of alcohol b. Loss of employment d. Poverty

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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 13. After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Safe, Effective Care Environment 17. An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "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 impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Safe, Effective Care Environment 19. An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: 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.

A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 541-542 | Page 547-548 TOP: Nursing Process: Evaluation

abc

A 10-year-old 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 as priorities 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 give support d. A safety plan for the wife and children e. Placing the children in foster care

emotional abuse

A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." What is this situation an example of?

abc

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest 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 an interview with these parents? (Select all that apply.) a. "Tell me how you discipline 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 spank your children?" e. "Calling children 'stupid' injures their self-esteem."

acefg

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.) a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone 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. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

A nurse plans to give secondary prevention to a patient who was sexually abused. Which action by the nurse indicates effective nursing practice? Select all that apply. a. The nurse treats the injuries of the patient. b. The nurse identifies families at high risk for abuse. c. The nurse teaches mindfulness techniques to the patient. d. The nurse arranges a housekeeper for the patient's family. e. The nurse arranges a legal advocacy program for the patient.

A patient tells the nurse, "My husband lost his job. He's abusive only 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

A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

bce

A woman reports being in an abusive relationship with her husband. What drives a man to act as a perpetrator in an abusive relationship? Select all that apply. a. He forces his partner to work because he feels idle. b. He feels more powerful when he uses force and abuse. c. He feels he is in charge and dominant in the relationship. d. He uses physical aggression because he hates his partner. e. He imposes restrictions due to extreme pathological jealousy.

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

Client Needs: Safe, Effective Care Environment 3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest 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 an interview with these parents? Select all that apply. a. "Tell me how you discipline 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 spank your children?" e. "Calling children 'stupid' injures their self-esteem."

A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 535-537 (Box 28-3) TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment MULTIPLE RESPONSE 1. A 10-year-old 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 as priorities 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 give support d. A safety plan for the wife and children e. Placing the children in foster care

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 would not be a priority at this time. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 544-545 | Page 548 (Nursing Care Plan 28-1) TOP: Nursing Process: Planning

Client Needs: Safe, Effective Care Environment 2. A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone 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. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

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. 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543-544 (Box 28-6) TOP: Nursing Process: Planning

14. A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis? 1. The client will name own body parts as separate from others by day five. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day four. 4. The client will not harm self or others by discharge.

ANS: 1 Rationale: An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities, such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis disturbed personal identity. Which outcome would best address this client diagnosis? 1. The client will name own body parts as separate from others by day five. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day four. 4. The client will not harm self or others by discharge.

12. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome? 1. Neuroleptic medications 2. Anti-manic medications 3. Tricyclic antidepressant medications 4. Monoamine oxidase inhibitor medications

A nursing instructor presents a case study in which a three-year-old child is in constant motion and is unable to sit still during story time. She asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? 1. "This child's behavior must be evaluated according to developmental norms." 2. "This child has symptoms of attention deficit-hyperactivity disorder." 3. "This child has symptoms of the early stages of autistic disorder." 4. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: 1 Rationale: The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. The DSM-5 indicates that emotional problems exist if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning

15. A nursing instructor presents a case study in which a three-year-old child is in constant motion and is unable to sit still during story time. She asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? 1. "This child's behavior must be evaluated according to developmental norms." 2. "This child has symptoms of attention deficit-hyperactivity disorder." 3. "This child has symptoms of the early stages of autistic disorder." 4. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

21. Which of the following risk factors, if noted during a family history assessment, should a nurse associate with the development of IDD? (Select all that apply.) 1. A family history of Tay-Sachs disease 2. Childhood meningococcal infection 3. Deprivation of nurturance and social contact 4. History of maternal multiple motor and verbal tics 5. A diagnosis of maternal major depressive disorder

16. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of IDD? 1. Risk for injury R/T self-mutilation 2. Altered social interaction R/T non-adherence to social convention 3. Altered verbal communication R/T delusional thinking 4. Social isolation R/T severely decreased gross motor skills

17. A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? 1. If one dose of Ritalin is missed, double the next dose. 2. Administer Ritalin to the child after breakfast. 3. Administer Ritalin to the child just prior to bedtime. 4. A side effect of Ritalin is decreased ability to learn.

ANS: 2 Rationale: The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? 1. If one dose of Ritalin is missed, double the next dose. 2. Administer Ritalin to the child after breakfast. 3. Administer Ritalin to the child just prior to bedtime. 4. A side effect of Ritalin is decreased ability to learn.

10. A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

13. Which behavioral approach should a nurse use when caring for children diagnosed with disruptive behavior disorders? 1. Involving parents in designing and implementing the treatment process 2. Reinforcing positive actions to encourage repetition of desirable behaviors 3. Providing opportunities to learn appropriate peer interactions 4. Administering psychotropic medications to improve quality of life

22. Which of the following findings should a nurse identify that would contribute to a client's development of ADHD? (Select all that apply.) 1. The client's father was a smoker. 2. The client was born 7 weeks premature. 3. The client is lactose intolerant. 4. The client has a sibling diagnosed with ADHD. 5. The client has been diagnosed with dyslexia.

11. A preschool child diagnosed with autistic spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with neuroleptic medications. 3. Hold client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.

19. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's ADHD. Which nursing response best addresses the mother's concern? 1. "The physician will probably switch from Ritalin to a central nervous system stimulant." 2. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." 3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." 4. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: 3 Rationale: The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is a central nervous system stimulant, and tolerance can develop rapidly. Physical and psychological dependence can also occur.

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's ADHD. Which nursing response best addresses the mother's concern? 1. "The physician will probably switch from Ritalin to a central nervous system stimulant." 2. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." 3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." 4. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

18. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? 1. Modify environment to decrease stimulation and provide opportunities for quiet reflection. 2. Convey unconditional acceptance and positive regard. 3. Recognize escalating aggressive behavior and intervene before violence occurs. 4. Provide immediate positive feedback for appropriate behaviors.

ANS: 3 Rationale: The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behavior and to intervene before violence occurs. This intervention serves to keep the client as well as others safe, which is the priority nursing concern.

Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? 1. Modify environment to decrease stimulation and provide opportunities for quiet reflection. 2. Convey unconditional acceptance and positive regard. 3. Recognize escalating aggressive behavior and intervene before violence occurs. 4. Provide immediate positive feedback for appropriate behaviors

20. After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed symptom would a student nurse recognize? 1. Arguing and annoying older sibling over the past year 2. Angry and resentful behavior over a three-month period 3. Initiating physical fights for more than 18 months 4. Arguing with authority figures for more than six months

ANS: 4 Rationale: The DSM-5 rules out the diagnosis of ODD when only siblings are involved in argumentative interactions. Angry and resentful behavior over more than six months, not three months, would be considered a symptom of ODD. Initiating physical fights is a symptom of conduct disorder, not ODD. Arguing with authority figures for more than six months is listed by the DSM-5 as a symptom for the diagnosis of ODD.

After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed symptom would a student nurse recognize? 1. Arguing and annoying older sibling over the past year 2. Angry and resentful behavior over a three-month period 3. Initiating physical fights for more than 18 months 4. Arguing with authority figures for more than six months

1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual developmental disorder (IDD)? 1. The client can perform some self-care activities independently. 2. The client has more advanced speech development. 3. Other than possible coordination problems, the client's psychomotor skills are not affected. 4. The client communicates wants and needs by "acting out" behaviors.

ANS: 4 Rationale: The nurse should identify that a client diagnosed with severe IDD may communicate wants and needs by "acting out" behaviors. Severe IDD indicates an IQ between 20 and 34. Individuals diagnosed with severe IDD require complete supervision and have minimal verbal skills and poor psychomotor development.

22. The spouse of a patient in hospice care angrily tells the nurse, "The care provided by the aide and other family members is inadequate, so I must do everything myself. Can't anyone do things right?" The palliative care nurse should: a. provide teaching about anticipatory grieving. b. assign new personnel to the patient's care. c. arrange hospitalization for the patient. d. refer the spouse for crisis counseling.

ANS: A The behaviors described in this scenario are consistent with anticipatory grieving. The spouse needs to be taught about the process of anticipatory grieving and to receive counseling to validate what she is experiencing and to enhance coping. The incorrect options are not appropriate to the situation and do not respond to the spouse's needs.

24. Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: a. sympathy b. assertiveness training c. sexual self-awareness d. effective communication

ANS: C Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distracters are not prerequisites.

16. A terminally ill patient says, "I know I'm not going to get well, but still..." and the patient's voice trails off. Which response by the nurse would be therapeutic? a. "What do you hope for?" b. "No, you're not going to get well." c. "Do you have questions about what is happening?" d. "I'm happy you are being realistic about your future."

ANS: A This open-ended response is an example of following the patient's lead. It provides an opportunity for the patient to speak about whatever is on his or her mind. The incorrect options are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

7. After being notified that her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, "He'd still be alive if you'd given him your undivided attention!" Select the nurse's best response. a. "I understand you're feeling upset. Let's go to our conference room, and I'll stay with you until your family comes." b. "Your husband's heart was severely damaged and could no longer pump. There's nothing anyone could have done." c. "I will call the nursing supervisor to discuss this matter with you." d. "It will be all right if you cry. Crying is a normal grief response."

ANS: A When a bereaved family member behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. Moving the individual to a private area so as not to disturb others is important. The incorrect options are defensive, evasive, or placating.

13. A patient with whom the nurse is discussing advance directives asks, "What advantage does a durable power of attorney for health care have over a living will?" The nurse should reply that a durable power of attorney for health care: a. "Gives your agent the authority to make decisions about your care if you are unable to during any illness." b. "Can be given only to a relative, usually the next of kin, who has your best interests at heart." c. "Authorizes your physician to make decisions about your care that are in your best interest." d. "Can be used only if you have a terminal illness and become incapacitated."

ANS: A A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual's agent in the event that he or she is unable to make medical decisions. The patient does not have to be terminally ill or incompetent for the appointed person to act on his or her behalf.

9. If an older adult patient must be physically restrained, who is responsible for the patient's safety? a. Nurse assigned to care for the patient b. Nursing assistant who applies the restraint c. Health care provider who ordered the application of restraint d. Family member who agrees to the application of the restraint

ANS: A Although restraint is ordered by a health care provider, it is carried out by a nursing staff member. The nurse caring for the patient is responsible for the safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint but remain responsible for outcomes. Even when the family agrees to restraint, nurses are responsible for providing safe outcomes.

24. The highest priority for assessment by nurses caring for older adults who self-administer medications is: a. use of multiple drugs with anticholinergic effects b. overuse of medications for erectile dysfunction c. misuse of antihypertensive medications d. trading medications with acquaintances

ANS: A Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The incorrect options are relevant but are not of the highest priority.

The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with: a. attention deficit hyperactivity disorder. b. posttraumatic stress disorder. c. communication disorder. d. an anxiety disorder.

ANS: A Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with attention deficit hyperactivity disorder. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.

*A child diagnosed with attention deficit hyperactivity disorder will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications?* a. Central nervous system stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics

ANS: A Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with attention deficit hyperactivity disorder. The other medication categories listed would not be appropriate.

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child has been raised by a parent with chronic major depression. b. The child's best friend was absent from the child's birthday party. c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.

ANS: A Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk- enhancing.

21. An SSRI is prescribed for an older adult patient with depression. Nursing assessment should include careful collection of information regarding: a. use of other prescribed medications and over-the-counter products. b. evidence of pseudoparkinsonism or tardive dyskinesia. c. history of psoriasis and any other skin disorders. d. history of diarrhea and electrolyte imbalances.

ANS: A Drug interactions, with both prescription and over-the-counter products, can be problematic for the geriatric patient taking an SSRI. Careful collection of information is important. The incorrect options do not pose problems with SSRIs.

14. A patient says, "I often make careless mistakes and have trouble staying focused. Sometimes it's hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment." Which problem should the nurse document? a. Inattention b. Impulsivity c. Hyperactivity d. Social impairment

ANS: A Inattention refers to the failure to stay focused. A number of the other problems are the result of failure to pay attention, which contributes to problems with organization. Impulsivity refers to acting without thinking through the consequences. Hyperactivity refers to excessive motor activity. Social impairment refers to the failure to use appropriate social skills.

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.

8. A patient who is severely and persistently mentally ill and lives in a homeless shelter has the nursing diagnosis Powerlessness. Which intervention should be included in the plan of care? a. Encourage mutual goal setting. b. Verbally communicate empathy. c. Reinforce participation in activities. d. Demonstrate an accepting attitude.

ANS: A Mutual goal setting is an intervention designed to promote feelings of personal autonomy and dispel feelings of powerlessness. Although it might be easier and faster for the nurse to establish a plan and outcomes, this action contributes to the patient's sense of powerlessness. Involving the patient in decision making empowers the patient and reduces feelings of powerlessness.

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.

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.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child 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 passive temperament. c. is at risk for posttraumatic stress disorder. d. uses intellectualization to deal with problems.

8. A health care provider writes these new prescriptions for a resident in a skilled care facility: 2 G sodium diet; restraint as needed; limit fluids to 2000 ml daily; 1 dose milk of magnesia 30 ml orally if no bowel movement occurs for 3 days. Which prescription should the nurse question? a. Restraint b. Fluid restriction c. Milk of magnesia d. Sodium restriction

ANS: A Restraints may be applied only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other orders may be appropriate for implementation.

26. A nurse cares for a patient with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic medication d. Mood stabilizer

ANS: A SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder.

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.

23. When admitting older adult patients, health care agencies receiving federal funds must provide written information about: a. advance health care directives b. the financial status of the institution c. how to sign out against medical advice d. the institution's policy on the use of restraints

ANS: A The Patient Self-Determination Act of 1990 requires that patients have the opportunity to prepare advance directives.

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.

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.

Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Social isolation b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

ANS: A This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario.

26. A nurse wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data? a. "What thoughts do you have about a person's right to take his or her own life?" b. "If you felt suicidal, would you communicate your feelings to anyone?" c. "Do you have any risk factors that potentially contribute to suicide?" d. "Do you think you are vulnerable to developing a depressed mood?"

ANS: A This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, then no further assessment is necessary. If the patient deems suicide as acceptable, then the nurse can continue to assess the patient's intent, plan, and means to carry out the plan, as well as the lethality of the chosen method. The incorrect options are less direct.

2. An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? Select all that apply. a. Psychoeducation classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention

ANS: A, B, C The patient does not understand the illness and the need for adhering to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. Work gives meaning and purpose to life; vocational rehabilitation can assist with this aspect of care. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with severe mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking down the skill into small verbal and nonverbal components. The patient presently has a home and does not require the services of a homeless shelter. The nurse case manager functions in the role of crisis stabilizer, so no related referral is needed.

1. Which information should a nurse include in health teaching for adults who have with attention deficit hyperactivity disorder (ADHD) and their significant others? Select all that apply. a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement to help modify behaviors d. Psychostimulants for children (rarely effective in adults) e. Cognitive therapy to challenge internalized negative beliefs about self

ANS: A, B, E Evidence suggests that ADHD has a biological basis. This fact can help adults with the disorder to cope with lowered self-esteem that is often the result of negative treatment and a lack of acceptance in childhood. Cognitive therapy is helpful in reframing negative beliefs about self. Adults with ADHD have a higher incidence of substance abuse problems. The other options are untrue.

4. Which statements most clearly indicate that the speaker views mental illness with stigma? Select all that apply. a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working."

ANS: A, B, E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.

1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? Select all that apply. a. Failure of older adults to receive necessary medical information b. Development of public policy that favors programs for older adults c. Staff shortages because caregivers prefer working with younger adults d. Perception that older adults consume a small share of medical resources e. More ancillary than professional personnel discriminate with regard to age

ANS: A, C Because of society's negative stereotyping of older adults as having little to offer, some staff members avoid working with older patients. Staff shortages in long-term care facilities are often greater than those for acute care settings. Older adult patients often receive less information about their conditions and are offered fewer treatment options than younger patients; some health care staff members perceive them as less able to understand. This problem exists among professional and ancillary personnel. Public policy discriminates against programs for older adults. Societal anger exists because older adults are perceived to consume a disproportionately large share of the medical resources.

3. Psychotherapy for individuals at risk for complicated grief focuses on which goals? Select all that apply. a. Exploring emotional responses to a loss b. Identifying ways to break bonds with the deceased c. Solving problems related to moving forward in life d. Learning about the stages and symptoms of grieving e. Using antipsychotic medications for dysfunctional grief

ANS: A, C, D therapy is offered when a problem—not necessarily dysfunctional grief—exists or is anticipated. It focuses on emotional responses to loss and problem solving related to moving forward in life. Anxiety and/or depression may develop, even with normal grief, and require the short-term use of anxiolytic or antidepressant medications; however, antipsychotic drugs would not be expected. Physical symptoms such as weakness, anorexia, shortness of breath, tightness of the chest, dry mouth, and gastrointestinal disturbances may accompany acute grief, but the development of actual complications indicates dysfunctional grief.

3. Which economic factors are most critical to the success of discharge planning for a patient with severe and persistent mental illness? Select all that apply. a. Access to housing b. Individual psychotherapy c. Income to meet basic needs d. Availability of health insurance e. Ongoing interdisciplinary evaluation

ANS: A, C, D The success of discharge planning requires careful attention to the patient's economic status. Access to housing is the first priority of the seriously mentally ill, and lack of income and health insurance is a barrier to effective treatment and rehabilitation. Although important aspects of ongoing care of the seriously mentally ill patient, ongoing interdisciplinary evaluation and individual psychotherapy are not economic factors.

2. Which statements by a patient who is terminally ill give the nurse information relevant to spiritual assessment? Select all that apply. a. "I feel an inner peace with my decision to use hospice services." b. "I trust my health care provider to prescribe enough medication to keep me free of pain." c. "I have prepared advance directives to spare my children the need to make difficult decisions." d. "I plan to use these last weeks to experience the process of dying as fully as I experienced the richness of living." e. "Listening to hymns helps deepen my relaxation and the relief I get from my pain medication."

ANS: A, D, E Spirituality encompasses finding meaning in the process of living and dying, as well as hope and inner peace. Listening to hymns identifies an activity that connects the patient to his or her beliefs and is helpful in calming anxieties. The other options are not directly related to spiritual aspects.

6. Shortly after a man's wife dies, the man approaches the nurse who cared for his wife during her final hours of life and says angrily, "If you had given your undivided attention, she would still be alive." Which analysis applies? a. The comment summarizes the nurse's inadequacies. b. Anger is a phenomenon experienced during grieving. c. The patient had ambivalent feelings about his spouse. d. In some cultures, grief is expressed solely through anger.

ANS: B Anger may protect the bereaved from facing the devastating reality of the loss. Anger expressed during mourning is not directed toward the nurse, personally, although accusations and blame may make him or her feel as though it is.

19. As death approaches, a patient diagnosed with acquired immunodeficiency syndrome (AIDS) says, "I don't want to see a lot of visitors anymore. Just my parents and my sibling can come in for a while each day." What action should the nurse take? a. Ask the patient to reconsider the decision because many interested and caring friends can be sources of support. b. Discuss the request with the parents and sibling. Suggest that they explain the patient's decision to friends. c. Suggest that the patient discuss these wishes with the health care provider. d. Place a "no visitors" sign on the patient's door.

ANS: B As many patients approach death, they begin to withdraw. In the stage of acceptance, many patients are exhausted and tired, and interactions of a social nature are a burden. Many prefer to have someone present at the bedside who will sit without constantly talking. The correct response demonstrates the nurse's advocacy for the patient's preferences.

9. The mourning process is more difficult when the bereaved: a. was relatively independent of the deceased. b. has experienced a number of previous losses. c. accepts that death is expected for older adults. d. had few unresolved conflicts with the deceased.

ANS: B Factors that have negative effects on the mourning process include a high dependency on the deceased, ambivalence toward the deceased, a poor or absent support system, a high number of past losses or other recent losses, poor physical or mental health, and young age of the deceased. Data do not support the incorrect options.

20. A nurse manager notices that a staff member spends minimal time with a patient diagnosed with AIDS who is terminally ill. The patient says, "I'm having intense emotional reactions to this illness. Sometimes I feel angry, but other times I feel afraid or abandoned." The nurse manager can correctly hypothesize that the most likely reason for the staff member's avoidance is: a. fear of infection transmission. b. feelings of inadequacy in dealing with complex emotional needs. c. knowledge that the patient needs time alone with family and friends. d. belief that the patient's former lifestyle included high-risk behaviors.

ANS: B Many nurses tend to be more comfortable with meeting physical needs than in focusing on complex emotional needs. Standard precautions are necessary for all patients. The patient's lifestyle is irrelevant.

17. A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how close he is to death or how sad I am." Which response by the nurse would be most therapeutic? a. "You're right to protect him at a time when he is so vulnerable." b. "He might be more comforted than disturbed by your tears." c. "It's important for you to know that time is running out." d. "You definitely need to be honest about your feelings."

ANS: B Many people try to protect the dying person from experiencing emotions; however, emotional honesty is important to both the patient and the family. The patient may be comforted to know that the family is facing the inevitable. Giving advice and making judgmental statements are not helpful.

25. A nurse and social worker co-lead a reminiscence group for eight "elite-old" adults. Which activity is appropriate to include in the group? a. Performing mild aerobic exercises b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

ANS: B "Elite-old" adults are persons over 94 years of age; they were young during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

5. After the death of his wife, a man tells the nurse, "I can't live without her. She was my whole life." Which is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "Remember, she's no longer suffering." d. "Your friends will help you cope with this."

ANS: B The correct response demonstrates the use of reflection, a therapeutic communication technique. A statement that validates the bereaved person's loss is more helpful than banalities and clichés; it signifies understanding. The other options are clichés.

23. An individual was killed during a store robbery 2 weeks ago. The widowed spouse, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about the death. Which is the nurse's most therapeutic comment? a. "I'm worried about how much you're crying. Your grief over your spouse's death has gone on too long." b. "The unexpected death of your spouse must be painful. I'm glad you're able to talk to me about your feelings." c. "This loss is harder to accept because of your mental illness. Let's refer you to the partial hospitalization program." d. "Your crying shows me you aren't coping well. I made an appointment for you to see the psychiatrist for medication adjustment."

ANS: B The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for dysfunctional grieving because of the history of a severe psychiatric illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. The patient's crying 2 weeks after the spouse's death is expected and normal.

13. Which finding indicates the successful completion of an individual's grieving process? a. For two years, a person has kept the deceased spouse's belongings in their usual places. b. After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse. c. Three years after the death, a person talks about the spouse as if the spouse was still alive and weeps when others mention the spouse's name. d. Eighteen months after the spouse's death, a person says, "I never cry or have feelings of loss even though we were always very close."

ANS: B The work of grieving is over when the bereaved can remember the individual realistically and acknowledge both the pleasure and disappointments associated with the loved one. The individual is then free to enter into new relationships and activities. The other options suggest unresolved grief.

4. A person whose spouse died two years earlier tells friends, "I think I'll start going out socially, maybe even take someone to dinner." This comment best demonstrates that the individual is: a. denying the significance of the loss. b. in a period of resolution of grief. c. actively working through grief. d. experiencing intrusion.

ANS: B Toward the end of the grief process, the person renews his or her interest in people and activities. This behavior indicates resolution. At the same time, the person is released from the relationship with the deceased. The patient has progressed beyond grief. The patient is seeking to move into new relationships so that he or she is not alone.

20. A clinic nurse interviews four patients between 70 and 80 years of age. Which patient should have further assessment regarding the risk of alcohol dependence? The patient: a. with a history of intermittent problems of alcohol misuse early in life and who now consumes one glass of wine nightly with dinner. b. with no history of alcohol-related problems until age 65 years, when the patient began to drink alcohol daily "to keep my mind off my arthritis." c. who drank socially throughout adult life and continues this pattern, saying, "I've earned the right to do as I please." d. who abused alcohol between the ages of 25 and 40 years but now abstains and occasionally attends Alcoholics Anonymous.

ANS: B Alcohol dependence can develop at any age, and the geriatric population is particularly at risk. The geriatric problem drinker is defined as someone who has no history of alcohol-related problems but develops an alcohol-abuse pattern in response to the stresses of aging.

22. An adult man tells the nurse, "All my life, I have felt and acted like a woman while living in the body of a man. For the past year, I have lived and dressed as a woman. I'm changing jobs to protect my new identity." Which request is the patient likely to make to the health care provider? a. "Can you refer me for psychological testing?" b. "Will you prescribe estrogen therapy?" c. "Will you alter my medical records?" d. "What should I tell my parents?"

ANS: B Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient's decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point.

18. An adult with attention deficit hyperactivity disorder (ADHD) says, "I've always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can't keep a job." The nurse managing care should first consider: a. Aversive therapy to extinguish negative behaviors b. Cognitive therapy to help address internalized beliefs c. Group therapy to allow comparison of feelings with others d. Vocational counseling to identify needed occupational skills

ANS: B Cognitive therapy and knowledge of ADHD will make it possible for the patient to reframe the past and present in a more positive and realistic light and to challenge internalized false beliefs about self. Aversive therapy would not be useful for the patient. Group therapy may be valuable later to allow for the testing of new coping behaviors in a safe environment. Vocational counseling can help the patient explore suitable career options while pursuing treatment.

15. A nurse prepares for an initial interview with a patient with suspected adult ADHD. Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania

ANS: B Inattention usually persists from childhood into adult ADHD, although hyperactivity, impulsivity, and social impairments may also be present. Headaches would not be expected. Sexual impulses may be affected by adult ADHD, but this area is assessed later. Trichotillomania refers to pulling out one's hair as a tension-relieving behavior.

17. The treatment team believes medication will help a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which class of medications does the nurse expect will be prescribed? a. Benzodiazepines b. Psychostimulants c. Antipsychotics d. Anxiolytics

ANS: B Psychostimulants, such as methylphenidate and amphetamines, provide the basis for treatment of both adult and childhood ADHD. They are the most commonly used medications; therefore the nurse could expect the health care provider to prescribe a drug in this class. None of the other drugs listed as options have proven useful in the treatment of ADHD.

19. A 74-year-old patient is regressed and apathetic and responds to others only when they initiate the interaction. What form of therapy would be most useful to promote resocialization? a. Life review b. Remotivation c. Group psychotherapy d. Individual psychotherapy

ANS: B Remotivation therapy is designed to resocialize patients who are regressed and apathetic by focusing on a single topic, creating a bridge to reality as group members talk about the world in which they live and work, and hobbies related to the topic. Group leaders give group members acceptance and appreciation.

19. A new staff nurse tells the clinical nurse specialist, "I'm unsure about my role when patients bring up sexual problems." Which information should the clinical nurse specialist provide? All nurses: a. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples.

ANS: B The basic education of nurses provides information sufficient to qualify as a generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy require additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors; additional education is necessary. The registered nurse may provide basic information about sexual function, but complex questions may require referral.

A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action? a. Give notice to the chief administrator at the school regarding the events. b. Encourage the victimized child to share feelings about the experience. c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.

ANS: B The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child's complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

10. For patients with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. more efficiently use resources as the only manager responsible for coordinating services. c. focus on social skills training and self-esteem building. d. bring groups of patients together to discuss common problems.

ANS: B The case manager not only provides entrance into the system of care, but he or she also coordinates the multiple referrals that so often confuse the patient who is severely and persistently mentally ill and the patient's family. Case management promotes the efficient use of services. The other options are lesser advantages or may be irrelevant.

18. An 80-year-old patient has difficulty walking because of arthritis and says, "It's awful to be old. Every day is a struggle. No one cares about old people." Which is the nurse's most therapeutic response? a. "Everyone here cares about old people. That's why we work here." b. "It sounds like you're having a difficult time. Tell me about it." c. "Let's not focus on the negative. Tell me something good." d. "You are still able to get around, and your mind is alert."

ANS: B The nurse uses empathic understanding to permit the patient to express frustration and clarify the "struggle" for the nurse. The other options block communication.

16. In a sad voice, a patient tells the nurse of the recent deaths of a spouse of 50 years and their adult child in an automobile accident. The patient has no other family and only a few friends in the community. What is the priority nursing diagnosis? a. Spiritual distress, related to being angry with God for taking the family b. Risk for suicide, related to recent deaths of significant others c. Anxiety, related to sudden and abrupt lifestyle changes d. Social isolation, related to loss of existing family

ANS: B The patient appears to be experiencing normal grief related to the loss of the family; however, because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnosis of anxiety or spiritual distress. Risk for suicide is a higher priority than social isolation.

15. A 79-year-old white man tells a visiting nurse, "I've been feeling down lately. My family and friends are all dead. My money is running out, and my health is failing." The nurse should analyze this comment as: a. normal pessimism of older adults. b. evidence of suicide risk. c. a cry for sympathy. d. normal grieving.

ANS: B The patient describes the loss of significant others, economic insecurity, and declining health. He describes mood alteration and expresses the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Older adult white men have the highest risk for completed suicide.

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.

10. A health care provider decided that the emotional distress of an older adult patient who experiences threatening auditory hallucinations warrants the use of risperidone (Risperdal). Which intervention should the nurse add to the patient's plan of care? a. Use disposable briefs for incontinence. b. Monitor for psychomotor changes. c. Implement a tyramine-free diet. d. Monitor for dehydration.

ANS: B Use of atypical antipsychotic medications increases the risk of cerebrovascular events in the older adult population; therefore the nurse should carefully monitor the patient for psychomotor changes. This medication does not place the patient at great risk for the other options.

Which of the following medications is used to treat Tourette's Disorder? a. Methylphenidate (ritalin) b. Haloperidol (Haldol) c. Imipramine (Tofranil) d. phenytoin (Dilantin)

4. An older patient drinks a six-pack of beer daily. The patient tells the community health nurse, "I've been having trouble with my arthritis lately, so I take acetaminophen four times a day for pain." What are the nurse's priority interventions? Select all that apply. a. Inquiring about sleep disturbances caused by mixing alcohol and analgesic medications b. Determining the safety of the daily acetaminophen dose the patient is ingesting c. Advising the patient of the harmful effects of alcohol and acetaminophen on the liver d. Suggesting an increase in the acetaminophen dose because alcohol causes faster excretion e. Assessing the patient for declining functional status associated with medication-induced dementia

ANS: B, C The nurse should be concerned with the patient's use of alcohol and acetaminophen because the toxicity of acetaminophen is enhanced by alcohol and by the age-related decrease in clearance. The nurse must determine whether the acetaminophen dose is within safe limits or is excessive and provide this information to the patient. Next, the nurse must provide health education regarding the danger of combined use of acetaminophen and alcohol. The patient will need to discontinue or reduce alcohol intake. Another analgesic with less hepatotoxicity could be used. Additional acetaminophen would cause greater liver damage. The scenario does not suggest dementia.

At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? Select all that apply. a. Report the finding to the official child protection social services agency. b. Educate all members of the family about risks associated with cyberbullying. c. Talk with the parents about parental controls on the children's communication devices. d. Encourage the family to schedule daily time together without communication devices. e. Obtain the family's network password and examine online sites family members have visited.

ANS: B, C, D Education and awareness-based approaches have a chance of effectively reducing harmful online behavior, including risks associated with cyberbullying. Parental controls on the children's devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family's network password and an invasion of privacy to inspect sites family members have visited.

2. Which beliefs facilitate the provision of safe, effective care for older adult patients? Select all that apply. a. Sexual interest declines with aging. b. Older adults are able to learn new tasks. c. Aging results in a decline in restorative sleep. d. Older adults are prone to become crime victims. e. Older adults are usually lonely and socially isolated.

ANS: B, C, D Myths about aging are common and can negatively impact the quality of care older patients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery.

3. A nurse assessing an older adult patient for suicide potential should include questions about mood and which other symptoms? Select all that apply. a. Increased appetite b. Sleep pattern changes c. Anhedonia and anergia d. Increased social isolation e. Increased concern with bodily functions

ANS: B, C, D, E These symptoms are often noted in older adult patients with depression. Somatic symptoms are often present but are missed by nurses as being related to depression. Anorexia, rather than hyperphagia, is observed in major depression. Low self-esteem is more often associated with major depression.

A nurse prepares to lead a discussion at a community health center regarding children's health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? Select all that apply. a. Autism b. Bullying c. Mental retardation d. Autism spectrum disorder e. Intellectual development disorder

ANS: B, D, E Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It's important for the nurse to use current terminology.

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 patient's fiancé died in an automobile accident several days ago. The patient reports crying and experiencing feelings of guilt and anger. This behavior is characteristic of which stage of acute grief? a. Denial b. Reorganization c. Development of awareness d. Preoccupation with the lost object

ANS: C As denial fades, an awareness of the finality of the loss develops and is accompanied by painful feelings of loss, anger with others, and guilt for taking or not taking specific actions. Reorganization implies the movement toward healing. Denial is manifested by the inability to believe the reality of an event. Preoccupation with the lost object would involve the patient dwelling on thoughts of the deceased.

11. A nurse talks with a person whose spouse died suddenly while jogging. Which is the appropriate statement for the nurse? a. "At least your spouse did not suffer." b. "It's better to go quickly as your spouse did." c. "The loss of your spouse must be very painful for you." d. "You'll begin to feel better after you get over the shock."

ANS: C The most helpful responses by others validate the bereaved person's experience of loss. Avoid banalities; they increase the individual's sense of isolation.

27. A nurse cared for a terminally ill patient for over a month and always looked forward to spending time with the patient. When the patient died, the nurse experienced sadness and felt mildly depressed. Eventually, the nurse explains these feelings to a mentor. The mentor should counsel the nurse: a. about stress-reduction strategies. b. to seek therapy for dysfunctional grief. c. about the experience of disenfranchised grief. d. to consider taking a leave of absence to pursue healing.

ANS: C The nurse is experiencing disenfranchised grief. Nurses often incur loss that is not openly acknowledged or publicly mourned. The loss of a patient may not be recognized or acknowledged by others; therefore the grief is solitary and uncomforted and may be difficult to resolve.

15. A patient diagnosed with metastatic brain cancer says, "I'm dying, but I'm still living. I want to be in control as long as I can." Which reply shows the nurse was actively listening? a. "Our staff will do their best to help you feel comfortable." b. "Most people do not know how to help and are afraid of death." c. "Your mind and spirit are healthy, although your body is frail." d. "You want people to stop focusing on your weaknesses."

ANS: C The patient is asking for acknowledgment that he or she is not totally sick; even in the terminal state, strengths and capabilities are present. The correct response provides that acknowledgment through use of reflection. The other responses are nontherapeutic.

8. An adult who was widowed 18 months ago says, "I can now remember good times we shared without getting upset. Sometimes I even think about the disappointments. I've become accustomed to sleeping in our bed alone." The work of mourning: a. is beginning. b. is progressing abnormally. c. is at or near completion. d. has not begun.

ANS: C The work of mourning has been successfully completed when the bereaved can remember both the positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

27. A nurse and social worker co-lead a reminiscence group for eight "young-old" adults. Which activity is most appropriate to include in the group? a. Performing mild aerobic exercises b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

ANS: C "Young-old" adults are persons 65 to 74 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group.

17. When making a distinction as to whether a patient is experiencing confusion related to depression or dementia, what information would be most important for the nurse to consider? a. The patient with dementia is persistently angry and hostile. b. Early morning agitation and hyperactivity occur in dementia. c. Confusion seems to worsen at night when dementia is present. d. A patient who is depressed is constantly preoccupied with somatic symptoms.

ANS: C Both dementia and depression in older adults may produce symptoms of confusion. Noting whether the confusion seems to increase at night, which occurs more often with dementia than with depression, will help distinguish whether depression or dementia is producing the confused behavior. The other options are not necessarily true.

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.

*A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which medication will the information focus on?* a. Paroxetine (Paxil) b. Imipramine (Tofranil) c. Methyphenidate (Ritalin) d. Carbamazepine (Tegretol)

ANS: C CNS stimulants are the drugs of choice for treating children with ADHD: Ritalin and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.

25. An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Dyspareunia c. Exhibitionism d. Sexual masochism

ANS: C Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Dyspareunia refers to painful intercourse. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer.

11. The father of a child with schizophrenia says, "I lost my job, so we have no health insurance." The mother says, "I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture." The sibling says, "My parents don't pay very much attention to me." These comments signify: a. life-cycle stressors b. psychobiologic issues c. family burden of mental illness d. stigma associated with mental illness

ANS: C Family burden refers to the meaning that the experience of living with a person who is mentally ill has for families. The stressors mentioned are not related to live-cycle issues. The stressors described are psychosocial. Stigma refers to shame and ridicule associated with mental illness.

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.

When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses: a. guided imagery. b. talk focused on a specific issue. c. play and talk about a play activity. d. group discussion about selected topics.

ANS: C 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.

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.

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.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy

ANS: C Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior? a. Increased expressiveness in communication with others b. Abilities to identify anxiety and implement self-control strategies c. Improved abilities to participate in cooperative play with other children d. Tolerates social interactions for short periods without disruption or frustration

ANS: C The goal is improvement in the child's hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.

*What is the nurse's priority focused assessment for side effects in a child taking methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?* a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

ANS: C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications.

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.

Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors? a. Disobedience b. Hyperactivity c. Impulsivity d. Anxiety

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

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.

The parent of a child diagnosed 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, severity, and are reduced or absent during sleep.

When a 5-year-old 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 activity. 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 going to a designated room or sitting on the periphery of an activity until the child gains self-control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient.

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.

A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? a. Therapeutic relationships provide an outlet for tension. b. Focusing on the strengths increases a person's self-esteem. c. Acceptance and trust convey feelings of security to the child. d. The child should express feelings rather than internalize them.

ANS: C Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response.

1. Which actions by a nurse contribute to protecting the rights of patients who are terminally ill? Select all that apply. a. Maintain hope for a positive prognosis. b. Hug the patient when sadness is expressed. c. Offer choices that promote personal control. d. Provide interventions that convey respect. e. Support the patient's quest for spiritual growth.

ANS: C, D, E The answers support the rights of the individual who is dying. Touch should be nurturing but may leave the patient uncomfortable and confused if inappropriate. Acting on false information robs a patient of the opportunity for honest dialog and places barriers to achieving end-of-life developmental opportunities.

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.

A nurse prepares the plan of care for a 15-year-old diagnosed 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. graduate from high school. b. live independently in an apartment. c. independently perform 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 the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.

27. A patient with severe and persistent mental illness who recently moved to a homeless shelter says, "My life is out of control. I'm like a leaf at the mercy of the wind." The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: a. Instilling hope b. Controlling anxiety c. Planning activities d. Developing personal autonomy

ANS: D

25. A widow grieving her husband's sudden death tells the nurse, "I'm not feeling well. Yesterday, I saw my husband walk through the door, stop, and smile at me. Then he just faded away." Which is the nurse's most appropriate action? a. Assess for recent substance abuse. b. Suggest a referral to the mental health clinic. c. Arrange for an evaluation for antidepressant medication. d. Counsel the widow that visualizations are a normal part of grieving.

ANS: D Grieving patients often dream about, visualize, think about, or search for the lost loved one. The patient should be told that this is considered a normal phenomenon and not a sign of mental illness. Visualization does not suggest substance abuse or mental illness in this case.

24. Children of a widowed parent confer with the nurse; their surviving parent repeatedly relates the details of finding the deceased parent not breathing, performing cardiopulmonary resuscitation, going to the hospital by ambulance, and seeing the pronouncement of death. The family asks, "What can we do?" The nurse should counsel the family: a. to share their own feelings with the surviving parent and ask for the retelling to stop. b. that retelling the story should be limited to once daily to avoid unnecessary stimulation. c. that retelling memories is to be expected as part of the aging process. d. that repeating the story is a helpful and a necessary part of grieving.

ANS: D Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy; repetition is a helpful and necessary part of grieving. Limits should not be placed on the retelling.

12. A recently widowed patient tells the health care provider, "I have so much epigastric discomfort. I wonder if I have an ulcer." Diagnostic tests are negative. The symptom demonstrates: a. early reorganization behavior. b. disorganization and depression. c. preoccupation with the deceased. d. normal phenomenon of mourning.

ANS: D Sensations of somatic distress are often experienced during the acute stage of grieving. They include tightness in the throat, shortness of breath, exhaustion, and pain or sensations such as those experienced by the dead person.

14. A child drowned while swimming in a local lake four years ago. Which behavior indicates that the parents are effectively coping with their loss? The parents: a. prohibit their other children from going swimming. b. keep a place set for the dead child at the family dinner table. c. keep their child's room exactly as the child left it four years ago. d. throw flowers on the lake at each anniversary date of the accident.

ANS: D The loss of a child is among the highest risk situations for dysfunctional grieving. The parents who throw flowers across the lake on each anniversary date of the accident are effectively using a ritual to express their feelings openly. The other behaviors indicate the parents are isolating themselves or denying their feelings or both.

26. A grieving patient tells a nurse, "It's been eight months since my spouse died. I thought I would feel better by now, but lately I feel worse. I have no energy. I am lonely, but I don't want to be around people. What should I do?" What is the nurse's best counsel? a. Seek psychotherapy. b. Become active in a church. c. Go to the spouse's grave every day. d. Understand this is a normal response.

ANS: D The patient needs understanding and support that the feelings are normal. Although feelings of depression generally decline over the period of a year after the death of a loved one, the decline is not linear. Loneliness and aimlessness are most pronounced 6 to 9 months after the death. The patient should be educated about normal phenomena experienced during bereavement. The other options are not clearly indicated.

21. A terminally ill patient tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity with willpower. I always gave my best and expected things to turn out well. I intend to die as I lived: optimistically." The nurse planning care for this patient recognizes a critical need to: a. provide aggressive pain and symptom management. b. help the patient reassess and explore existing conflicts. c. assist the patient to focus on the meaning in life and death. d. support the patient's use of personal resources to meet challenges.

ANS: D The patient whose intrinsic strength and endurance have been a hallmark often wishes to approach dying by staying optimistic and in control. Helping the patient use his or her resources to meet challenges is appropriate.

10. A patient newly diagnosed with pancreatic cancer says, "My father also died of pancreatic cancer. I took care of him during his illness. I can't go through that." Select the highest priority nursing diagnosis. a. Anticipatory grieving b. Ineffective coping c. Ineffective denial d. Risk for suicide

ANS: D The patient's statement has a subtle message of suicide. Suicide is a risk for people with major losses, including terminal disease. The nurse will need to monitor the suicide risk vigilantly. The other diagnoses may apply but are lower priority.

18. A family of a terminally ill patient asks the nurse, "What can we say when our family member mentions death is coming soon?" Which response could the nurse suggest? a. "We think you will be around for a long time." b. "We don't want you to give up trying to get well." c. "We don't think we're ready to talk about this yet." d. "We feel so sad when we think of life without you."

ANS: D This response is emotionally honest. It will allow the family opportunities to express emotions and further resolve issues in the relationship and explore end-of-life developmental opportunities. The incorrect options are evasive.

21. A patient tells the nurse, "My sexual functioning is normal when my partner wears lace. Without it, I'm not interested in sex." This comment evidences: a. exhibitionism b. voyeurism c. pedophilia d. fetishism

ANS: D A person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality, to be sexually satisfied. Exhibitionism refers to exposing one's genitalia publicly. Voyeurism refers to viewing others in intimate situations. Pedophilia refers to the preference for having sexual relations with a child.

9. Marco, age 83, has dementia and difficulty feeding himself despite the fact that there is nothing wrong with his motor functions. Which term should the nurse use to document this finding? a. Aphasia b. Apraxia c. Agnosia d. Disinhibition anergia

b. Apraxia

13. An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD)

ANS: D Adult ADHD is usually diagnosed in early life and treated until adolescence. Treatment is often stopped because professionals think the disorder resolves itself because the hyperactive impulsive behaviors may diminish; the inattentive and disorganized behaviors tend to persist, however. Stress intolerance disorder is not found in the DSM-IV-TR. The scenario description is inconsistent with generalized anxiety disorder and borderline personality disorder.

12. An advance directive gives valid direction to health care providers when a patient is: a. aggressive b. dehydrated c. unable to verbally communicate d. unable to make decisions for him- or herself

ANS: D Advance directives are invoked when patients are unable to make their own decisions. Aggression, dehydration, or an inability to speak does not mean the patient is unable to make a decision.

*A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child:* a. has occasional toileting accidents. b. is unable to read children's books. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

ANS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. The distracters are expected findings for a 3-year-old.

14. Recognizing the risk for acquired immunodeficiency syndrome (AIDS) among older adults, nurses should provide health teaching aimed at: a. discouraging sexual expression b. using birth controls measures c. avoiding blood transfusions d. encouraging condom use

ANS: D Because the risk for pregnancy is nonexistent in postmenopausal women, condom use is diminished, which places older adults at risk for AIDS and other sexually transmitted diseases. Safe sex continues to be important and should be taught to the older adult population. Little to no danger exists from blood transfusions.

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.

20. Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquiring knowledge of the patient's sexual roles and preferences b. Developing an understanding of human sexual responses c. Assessing the patient's sexual functioning d. Clarifying the nurse's own personal values

ANS: D Before a nurse can be helpful to patients with sexual dysfunction, he or she must be aware of and comfortable with his or her own feelings about sex and sexuality. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure.

5. Which statement about aging provides the best rationale for focused assessment of older adult patients? a. Older adults are often socially isolated and lonely. b. As people age, they become more rigid in their thinking. c. The majority of older adults sleep more than 12 hours per day. d. The senses of vision, hearing, touch, taste, and smell decline with age.

ANS: D Only the correct answer is true and cues the nurse to assess carefully the sensory functions of the older adult patient. The incorrect options are myths about aging.

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.

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.

11. An older adult patient brings a bag of medication to the clinic. The nurse finds one bottle labeled "Ativan" and one labeled "lorazepam," and both are labeled "Take two times daily." Bottles of hydrochlorothiazide, Inderal, and rofecoxib, each labeled "Take one daily," are also included. Which conclusion is accurate? a. Rofecoxib should not be taken with Ativan. b. The patient's blood pressure is likely to be very high. c. This patient should not self-administer any medication. d. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.

ANS: D Lorazepam and Ativan are generic and trade names for the same drug, creating an accidental misuse situation. The patient needs medication education and help with proper, consistent labeling of bottles; no evidence suggests that the patient cannot self-administer medication. The distracters are not factual statements.

22. An older adult patient with depression is being treated with sertraline (Zoloft). This medication is often chosen for older adult patients because it: a. has a high degree of sedation. b. is effective when given in smaller doses. c. has few adverse interactions with other drugs. d. is less affected by changes associated with aging.

ANS: D Older adults are particularly susceptible to side effects, so selecting a drug with a low side-effect profile is desirable. The pharmacokinetics of sertraline are less affected by changes associated with aging. The incorrect options are either incorrect or of lesser relevance.

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.

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.

12. The parent of an adult who is severely and persistently mentally ill asks the nurse, "Why are you making a referral to that vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported."

ANS: D Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment; also they demonstrate significant improvement in assertiveness and work behaviors, as well as decreased depression.

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.

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

ANS: D Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. Autistic spectrum disorder is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" Select the nurse's best response. a. "Ask the teacher to let the child call you at play time." b. "Withdraw the child from preschool until maturity increases." c. "Remain with your child for the first hour of preschool time." d. "Give your child a kiss before you leave the preschool program."

ANS: D The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

23. The manager of a health club put a hidden camera in the women's locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism

ANS: D Voyeurism is the viewing of others in intimate situations such as undressing, bathing, or having sexual relations. Voyeurs are often called "peeping Toms." Frotteurism is touching or rubbing against a nonconsenting person to achieve sexual gratification. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with prepubescent children.

*When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action?* a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.

ANS: D The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.

16. A nurse prepares a plan of care for a patient with adult attention deficit hyperactivity disorder (ADHD). Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing.

ANS: D The nurse's major responsibilities lie with encouraging the patient to learn and use necessary skills, assisting the patient to stay on task. The nurse is not an ever-present taskmaster or disciplinarian. The nurse does not teach work-related skills; vocational staff members assume those types of tasks.

5. A patient with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the cause of the patient's ineffective management of the medication regime as: a. inadequate discharge planning b. poor therapeutic alliance with clinicians c. dislike of the side effects of antipsychotic medications d. impaired reasoning secondary to the schizophrenia

ANS: D The patient's ineffective management of the medication regime is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence.

23. The DSM-5 criteria for ODD specifies that: A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness must be evident and last at least ______________ months.

ANS: six Rationale: A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness must be evident and last at least six months according to the DSM-5 criteria for the diagnosis of ODD.

emotional

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely?

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." 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

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

honeymoon

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving?

physical

An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring?

An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my 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 about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

Client Needs: Safe, Effective Care Environment 16. An older adult with Alzheimer's disease lives with family in a rural area. 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. Multiple caregivers c. Living in a rural area b. Alzheimer's disease d. Being part of a busy family

B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534-535 TOP: Nursing Process: Assessment

Client Needs: Safe, Effective Care Environment 14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 539 | Page 541-542 TOP: Nursing Process: Outcomes Identification

Client Needs: Safe, Effective Care Environment 18. An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my 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 about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

B The patient's caregivers 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 pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 546-547 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 20. Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group c. A women's shelter b. A mental health center d. Vocational counseling

C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537 | Page 544 (Box 28-6) TOP: Nursing Process: Implementation

Client Needs: Safe, Effective Care Environment 15. An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological c. Physical b. Financial d. Sexual

C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 537 (Box 28-4) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 12. An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building c. Honeymoon b. Acute battering d. Stabilization

C The honeymoon stage is characterized by kind, 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 stabilization stage. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534 TOP: Nursing Process: Assessment

2. Which statement made by a nurse requires immediate correction by the supervisor? a. "Many older patients are depressed." b. "Retirement is a difficult time for older patients." c. "Cognitive decline is normal in patients who are 65 and older." d. "Sleep-related problems are often reported by older adults."

c. "Cognitive decline is normal in patients who are 65 and older."

Client Needs: Safe, Effective Care Environment 10. A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. c. Call the adult protective agency. b. Arrange for hospitalization. d. Document injuries with a body map.

D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 540-541 | Page 548-549 (Nursing Care Plan 28-1) TOP: Nursing Process: Implementation

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has a. complaints of abdominal pain. b. repeated middle ear infections. c. bruises on extremities. d. diarrhea.

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who a. have been abused. b. are attention seeking. c. have eating disorders. d. are developmentally delayed.

1. During an interview with a patient, which question asked of an older adult is associated with the Patient Self-Determination Act? a. "Who besides yourself may have access to your medical information?" b. "Have you discussed your end-of-life choices with your family or designated surrogate?" c. "Do you have the information you need to make an informed decision about your treatment?" d. "How can I help you feel comfortable about this interview and any decisions you need to make?"

b. "Have you discussed your end-of-life choices with your family or designated surrogate?"

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding 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

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

When can a victim of abuse expect the abuse to worsen? a. When the perpetrator feels he or she is in complete control b. When the perpetrator is feeling remorseful for being abusive c. When the victim submits to the domination of the perpetrator d. When the victim moves toward independence from the abuser

acde

Which are risk factors for older adult abuse? Select all that apply. a. Female b. African American c. Over the age of 75 d. Living with a relative e. Physical or mental impairment

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

5. Which statement by an older patient with a mild neurocognitive disorder demonstrates a safe response to beginning a new medication? a. "I read the information the pharmacist gave me when I got the prescription filled." b. "My daughter comes with me to appointments so that we get all the information we need." c. "I know I can call my doctor if I think of any questions later." d. "I always follow the instructions on the medication bottle."

b. "My daughter comes with me to appointments so that we get all the information we need."

10. You are caring for Ellie, age 91, whose provider has written a "DNR-CCO" order. Which nursing action would be appropriate if Ellie were to go into cardiac arrest? a. Immediately call for the code team b. Notify the attending physician and family of the change in status c. Administer prescribed medication morphine for pain control d. Initiate cardiopulmonary resuscitation

b. Notify the attending physician and family of the change in status

6. Anxiety problems in older adults can manifest as a fear of falling, greatly influencing an older adult's personal freedom. A home health nurse checking on a patient with mild dementia and anxiety related to falling should question which new order? a. Yoga and tai-chi b. Xanax c. Relaxation techniques d. Electric wheelchair

b. Xanax

3. Considering psychosocial role theory, which patient demonstrates healthy adjustment to aging? a. The 70-year-old who is training for a 5-mile running race b. The older adult who controls diabetes with diet and exercise c. The retiree who volunteers 3 days a week at the local library d. The 80-year-old who is upbeat and hopeful during chemotherapy for lung cancer

c. The retiree who volunteers 3 days a week at the local library

7. Fred is an older adult with spinal stenosis and who is being treated with a short-term prescription of opioids for an acute episode of back pain. His nurse recognizes additional teaching is necessary when Fred states: a. "Sitting up straight seems to reduce the pain." b. "Sometimes I use a heating pad on my back." c. "Once I get moving for the day my pain gets better." d. "My wife and I share my Norco for our aches and pains."

d. "My wife and I share my Norco for our aches and pains."

8. Ling works as a registered nurse in an Alzheimer's care home. Ling has a specialized rapport-building technique she uses called reminiscence. She uses this technique by: a. Telling the residents stories about her grandparents' lives. b. Playing music from the residents' formative years. c. Reviewing movies that the residents enjoy. d. Encouraging the residents to talk about pleasurable past events.

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