PSYCH Chapters 14, 19, 27, 28
A patient diagnosed with severe and persistent mentally illness lives in a homeless shelter. The priority nursing diagnosis for this patient is 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.
a. Encourage mutual goal setting.
One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9 C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36 C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature, 36.5 C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7 C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg
a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9 C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg
The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
a. Consider each disorder primary and provide simultaneous treatment.
A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.
a. Conveying understanding that pressures associated with nursing practice underlie substance abuse.
In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided.
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, Describe what you think about your present weight and how you look. Which response by the patient is most consistent with the diagnosis? a. I am fat and ugly. b. What I think about myself is my business. c. I am grossly underweight, but thats what I want. d. I am a few pounds overweight, but I can live with it.
a. I am fat and ugly
A homeless patient diagnosed with severe and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication and housing was arranged at 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. Im not going to take any more of them.
a. I am feeling safe and comfortable here. Nobody bothers me
Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa? a. I would be happy if I could lose 20 more pounds. b. My parents dont pay much attention to me. c. Im thin for my height. d. I have nice eyes.
a. I would be happy if I could lose 20 more pounds
Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, I can maintain sobriety one day at a time. Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, My problems are under control. Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are real alcoholics and says, I may be able to help some of them find jobs at my company. d. Is abstinent for 21 days and says, I know I cant handle more than one or two drinks in a social setting.
a. Is abstinent for 10 days and states, I can maintain sobriety one day at a time. Spoke with employer, who is willing to allow the patient to return to work in three weeks.
Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.
a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped.
Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.
a. Monitor the airway and vital signs every 15 minutes.
If an older adult patient must be physically restrained, who is responsible for the patients 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
a. Nurse assigned to care for the patient
A nurse cares for a patient diagnosed 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
a. Selective serotonin reuptake inhibitor (SSRI)
A nurse and social worker co-lead a reminiscence group for six elite-old adults. Which activity is appropriate to include in the group? a. Singing a song from World War II b. Learning to send and receive email c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper
a. Singing a song from World War II
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 persons 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?
a. What thoughts do you have about a persons right to take his or her own life?
Physical assessment of a patient diagnosed with bulimia nervosa often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.
a. prominent parotid glands
In the emergency department, a patients vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome. a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. b. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. c. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment. d. The patient will identify two community resources for the treatment of substance abuse by discharge.
a. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
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 sad? 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?
a. Would you say your mood is often sad?
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 institutions policy on the use of restraints.
a. advance health care directives.
A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Bucks traction and screams, Somebody tied me up with ropes. The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.
a. an illusion
An outpatient diagnosed with anorexia nervosa has begun re-feeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.
a. assess lung sounds and extremities
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Explore patient needs for health teaching. d. Assess for signs of impulsive eating.
a. assist the patient to identify triggers to binge eating
A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? a. Cachexia b. Leukocytosis c. Hyperthermia d. Hypertension
a. cachexia
A patient in an alcohol treatment program says, I have been a loser all my life. Im so ashamed of what I have put my family through. Now, Im not even sure I can succeed at staying sober. Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance
a. chronic low self-esteem
A person diagnosed with severe and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurses initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices
a. develop a relationship
When working with a patient beginning treatment for alcohol abuse, what is the nurses most therapeutic approach? a. Empathetic, supportive b. Strong, confrontational c. Skeptical, guarded d. Cool, distant
a. empathetic, supportive
A patient asks the nurse, What advantage does a durable power of attorney for health care have over a living will? The nurse should reply, 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.
a. gives your agent the authority to make decisions about your care if you are unable to during any illness.
A community mental health nurse plans an educational program for staff members at 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.
a. identifying clinical depression in older adults.
A patient says, I often make careless mistakes and have trouble staying focused. Sometimes its 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
a. inattention
A patient asks for information about Alcoholics Anonymous (AA). Which is the nurses best response? a. It is a self-help group with the goal of sobriety. b. It is a form of group therapy led by a psychiatrist. c. It is a group that learns about drinking from a group leader. d. It is a network that advocates strong punishment for drunk drivers.
a. it's a self-help group with the goal of sobriety
A 78-year-old nursing home resident diagnosed 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 patients family lives 200 miles away. The nurse should first suspect that the resident: a. may be experiencing side effects associated with medications. b. may be developing Alzheimer disease associated with advanced age. c. had a transient ischemic attack and developed sensory perceptual alterations. d. has previously unidentified alcohol abuse and is beginning alcohol withdrawal delirium.
a. may be experiencing side effects associated with medications.
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
a. restraint
When a person first begins drinking alcohol, two drinks produce relaxation and drowsiness. After one year of drinking, four drinks are needed to achieve the same relaxed, drowsy state. Why does this change occur? a. Tolerance develops. b. The alcohol is less potent. c. Antagonistic effects occur. d. Hypomagnesemia develops.
a. tolerance develops
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.
a. use of multiple drugs with anticholinergic effects.
A selective serotonin reuptake inhibitor (SSRI) is prescribed for an older adult patient diagnosed with major depressive disorder. 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.
a. use of other prescribed medications and over-the-counter products.
During the third week of treatment, the spouse of a patient in an alcoholism rehabilitation program says, After discharge, Im sure everything will be just fine. Which remark by the nurse will be most helpful to the spouse? a. It is good that youre supportive of your spouses sobriety and want to help maintain it. b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol. c. It will be important for you to structure life to avoid as much stress as possible. You will need to provide social protection. d. Remember that alcoholism is a disorder of self-destruction. You will need to observe your spouses behavior carefully.
b. Although sobriety solves some problems, new ones may emerge as one adjusts to living without alcohol
A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)
b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped)
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 [nurses 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 dont mind. d. You look as though you are comfortable and ready to participate in an admission interview. Shall we get started?
b. Hello. My name is [nurses name]. I am a nurse. Please tell me how you would like to be addressed by the staff.
An 80-year-old patient has difficulty walking because of arthritis and says, Its awful to be old. Every day is a struggle. No one cares about old people. Which is the nurses most therapeutic response? a. Everyone here cares about old people. Thats why we work here. b. It sounds like youre having a difficult time. Tell me about it. c. Lets not focus on the negative. Tell me something good. d. You are still able to get around, and your mind is alert.
b. It sounds like youre having a difficult time. Tell me about it.
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs of the patient are met. d. Because of increased risk for physical problems with re-feeding, obtaining patient permission is required.
b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.
A 74-year-old patient is regressed and apathetic. This patient responds to others only when they initiate the interaction. Which therapy would be most useful to promote resocialization? a. Life review b. Remotivation c. Group psychotherapy d. Individual psychotherapy
b. Remotivation
A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurses drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.
b. Seeking to be assigned as a medication nurse.
What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. The nurses comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.
b. The nurse uses an authoritarian manner when interacting with the patient.
Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. Have you ever had blackouts? b. When did you have your last drink? c. Has drinking caused you any problems? d. When did you decide to seek treatment?
b. When did you have your last drink?
A man tells the nurse, All my life, I have felt and acted like a woman while living in a mans body. For the past year, I have lived and dressed as a woman. I changed 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?
b. Will you prescribe estrogen therapy?
A student nurse visiting a senior center tells the instructor, Its so depressing to see all these old people. They are so weak and frail. They are probably all confused. The student is expressing: a. reality. b. ageism. c. empathy. d. advocacy.
b. ageism
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. She wears layered, loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating disorder b. Anorexia nervosa c. Bulimia nervosa d. Pica
b. anorexia nervosa
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 patients pain before performing the assessment.
b. ask if the patient can hear clearly as the nurse speaks.
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate oral intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.
b. avoid skipping meals or restricting food
An adult diagnosed with attention deficit hyperactivity disorder (ADHD) says, Ive always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I cant keep a job. The nurse managing care should 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.
b. cognitive therapy to help address internalized beliefs.
Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane
b. disturbed thought processes
For patients diagnosed with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. efficiently access and use resources. c. focus on social skills training and self-esteem building. d. bring groups of patients together to discuss common problems.
b. efficiently access and use resources.
A 79-year-old white man tells a visiting nurse, Ive 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 negativity of older adults. b. evidence of suicide risk. c. a cry for sympathy. d. normal grieving.
b. evidence of suicide risk
Police bring a patient to the emergency department after an automobile accident. The patient is ataxic with slurred speech and mild confusion. The blood alcohol level is 400 mg/dl (0.40 mg %). Considering the relationship between behavior and blood alcohol level, which conclusion can the nurse draw? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has recently ingested both alcohol and sedative drugs.
b. has a tolerance for alcohol
A nurse prepares for an initial interview with a patient with suspected adult attention deficit hyperactivity disorder (ADHD). Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania
b. inattention
Severe and persistent mental illness is characterized as a: a. mental illness with longer than 2 weeks duration. b. major ongoing 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.
b. major ongoing mental illness marked by significant functional impairments.
Which nursing intervention has priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of re-feeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.
b. observe for adverse effects to re-feeding
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
b. psychostimulants
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism
b. rigidity, perfectionism
In a sad voice, a patient tells the nurse of the recent deaths of a spouse of 50 years as well as an 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
b. risk for suicide, related to recent deaths of significant others
A new staff nurse tells the clinical nurse specialist, Im 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.
b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths.
Select the most appropriate outcome for a patient completing the fourth alcohol detoxification program in one year. Before discharge, the patient will a. use rationalization in healthy ways. b. state, I see the need for ongoing treatment. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.
b. state, I see the need for ongoing treatment.
A patient diagnosed with severe and persistent mental illness lives independently. This patient has command hallucinations and shouts warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, You cant come back here. You cause too much trouble. What problem is the patient experiencing? a. Grief b. Stigma c. Recidivism d. Lack of insurance parity
b. stigma
A patient has smoked two packs of cigarettes daily for many years. When the patient does not smoke or tries to cut back, anxiety, craving, poor concentration, and headache result. What does this scenario describe? a. Substance abuse b. Substance addiction c. Substance intoxication d. Recreational use of a social drug
b. substance addiction
A clinic nurse interviews four patients between 70 and 80 years of age. Which patient should have further assessment regarding the risk of alcohol addiction? 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, Ive 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.
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.
A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority? a. Check the patient every 15 minutes. b. Rigorously encourage fluid intake. c. Provide one-on-one supervision. d. Keep the room dimly lit.
c. provide one-on-one supervision
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.
c. Confusion seems to worsen at night when dementia is present.
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. Singing a song from World War II b. Learning how to join an online social network c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper
c. Discussing national leadership during the Vietnam War
Which assessment findings best correlate to the withdrawal from central nervous system depressants? a. Dilated pupils, tachycardia, elevated blood pressure, elation b. Labile mood, lack of coordination, fever, drowsiness c. Nausea, vomiting, diaphoresis, anxiety, tremors d. Excessive eating, constipation, headache
c. Nausea, vomiting, diaphoresis, anxiety, tremors
A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, I feel terrible. Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.
c. Symptoms of opiate withdrawal are present.
A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patient's oral intake, the nurse should ask: a. Do you often feel fat? b. Who plans the family meals? c. What do you eat in a typical day? d. What do you think about your present weight?
c. What do you eat in a typical day?
A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, Often my friend drinks, along with taking more of the drug than is prescribed. What is the effect of the use of alcohol with this drug? a. The drugs metabolism is stimulated. b. The drugs effect is diminished. c. A synergistic effect occurs. d. There is no effect.
c. a synergistic effect occurs
A patient admitted yesterday for injuries sustained while intoxicated believes the window blinds are snakes trying to get into the room. The patient is anxious, agitated, and diaphoretic. Which medication can the nurse anticipate the health care provider will prescribe? a. Monoamine oxidase inhibitor, such as phenelzine (Nardil) b. Phenothiazine, such as thioridazine (Mellaril) c. Benzodiazepine, such as lorazepam (Ativan) d. Narcotic analgesic, such as morphine
c. benzodiazepine, such as lorazepam (Ativan)
Which nursing diagnosis is likely to apply to a homeless individual diagnosed with severe and persistent mental illness? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome
c. chronic low self-esteem
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. Frotteurism c. Exhibitionism d. Sexual masochism
c. exhibitionism
The father of a child diagnosed 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 dont 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.
c. family burden of mental illness
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, Snakes are crawling on my bed. Ive got to get out of here. What is the most accurate assessment of the situation? The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having a recurrence of an acute psychosis.
c. has symptoms of alcohol withdrawal delirium
A patient diagnosed with schizophrenia tells the community mental health nurse, I threw away my pills because they interfere with Gods voice. The nurse identifies the cause of the patients ineffective management of the medication regimen as: a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. impaired reasoning secondary to schizophrenia. d. dislike of the side effects of antipsychotic medications.
c. impaired reasoning secondary to schizophrenia.
As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which condition should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor
c. lanugo
While providing health teaching for a patient diagnosed with bulimia nervosa, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing symptoms of hypokalemia. d. self-esteem maintenance.
c. recognizing symptoms of hypokalemia
A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.
c. runny nose, yawning, insomnia, and chills.
Health maintenance and promotion efforts for patients diagnosed 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 patients support system.
c. screening for cancer, hypertension, and diabetes
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.
c. sexual self-awareness
An adult says, When I was a child, I took medication because I couldnt 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 (GAD) c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD)
d. Adult attention deficit hyperactivity disorder (ADHD)
An adult in the emergency department states, I feel restless. Everything I look at wavers. Sometimes Im outside my body looking at myself. I hear colors. I think Im losing my mind. Vital signs are slightly elevated. The nurse should suspect a: a. cocaine overdose. b. schizophrenic episode. c. phencyclidine (PCP) intoxication. d. D-lysergic acid diethylamide (LSD) ingestion.
d. D-lysergic acid diethylamide (LSD) ingestion.
Which assessment findings will the nurse expect in an individual who has just injected heroin? a. Anxiety, restlessness, paranoid delusions b. Heightened sexuality, insomnia, euphoria c. Muscle aching, dilated pupils, tachycardia d. Drowsiness, constricted pupils, slurred speech
d. Drowsiness, constricted pupils, slurred speech
A nurse prepares a plan of care for a patient diagnosed 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.
d. Give encouragement and strategies for managing and organizing.
Which nursing diagnosis is more applicable for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements
d. Imbalanced nutrition: less than body requirements
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The patients current serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia
d. Imbalanced nutrition: less than body requirements, related to malnutrition as evidenced by loss of 25% of body weight and hypokalemia
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, I wont eat until I look thin. What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation
d. Imbalanced nutrition: less than body requirements, related to self-starvation
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 patients 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.
d. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.
The parent of an adult diagnosed with severe and persistent mental illness asks the nurse, Why are you making a referral to that vocational rehabilitation program? My child wont ever be able to hold a job. Which is the nurses best reply? a. We make this referral to continue eligibility for federal funding. b. Are you concerned that were 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.
d. Most patients are capable of employment at some level, competitive or supported.
Disturbed body image is the nursing diagnosis for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.
d. Patient expresses satisfaction with body appearance
A patient with a history of daily alcohol abuse says, Drinking helps me cope with being a single parent. Which response by the nurse would help the individual conceptualize the drinking more objectively? a. Sooner or later, alcohol will kill you. Then what will happen to your children? b. I hear a lot of defensiveness in your voice. Do you really believe this? c. If you were coping so well, why were you hospitalized again? d. Tell me what happened the last time you drank.
d. Tell me what happened the last time you drank
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.
d. The senses of vision, hearing, touch, taste, and smell decline with age.
When a nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. You and I will have to sit down and discuss this problem. b. It bothers me to see you exercising. Youll lose more weight. c. Lets discuss the relationship between exercise and weight loss and how that affects your body. d. According to our agreement, no exercising is permitted until you have gained a specific amount of weight.
d. according to our agreement, no exercising is permitted until you have gained a specific amount of weight
When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.
d. anterograde amnesia
A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. What are your feelings about not eating the food that you prepare? b. You seem to feel much better about yourself when you eat something. c. It must be difficult to talk about private matters to someone you just met. d. Being thin does not seem to solve your problems. You are thin now but still unhappy.
d. being thin does not seem to solve your problems, you are thin now but still unhappy
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention Monitor for complications of re-feeding. Which body system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular
d. cardiovascular
Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquire knowledge of the patients sexual roles and preferences b. Develop an understanding of human sexual responses c. Assess the patients sexual functioning d. Clarify the nurses own personal values
d. clarify the nurses own personal values
Which assessment findings support a nurses suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia
d. confusion, mouth ulcers, and ataxia
A patient admitted to an alcoholism rehabilitation program says, Im just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and several drinks during the evening. The patient is using which defense mechanism? a. Rationalization b. Introjection c. Projection d. Denial
d. denial
A patient diagnosed with severe and persistent mental illness who recently moved to a homeless shelter says, My life is out of control. Im 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 social activities. d. developing personal autonomy.
d. developing personal autonomy.
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 control measures. c. avoiding blood transfusions. d. encouraging condom use.
d. encouraging condom use.
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurses first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway
d. establish a patent airway
A patient tells the nurse, My sexual functioning is normal when my partner wears lace. Without it, Im not interested in sex. This comment evidences: a. exhibitionism. b. voyeurism. c. pedophilia. d. fetishism.
d. fetishism
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.
d. gain 1 to 2 pounds
A nursing diagnosis for a patient diagnosed with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is, Within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.
d. identify two alternative methods of coping with loneliness
An older adult patient diagnosed with major depressive disorder 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.
d. is less affected by changes associated with aging.
A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.
d. microcephalic and cognitively impaired
Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)
d. naltrexone (Revia)
Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patients requests. d. Observe for depression and suicidal ideation.
d. observe for depression and suicidal ideation
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients concentration and attention. b. shifting the patients focus from food to psychotherapy. c. focusing on weight control mechanisms and food preparation. d. processing the heightened anxiety associated with eating.
d. processing the heightened anxiety associated with eating.
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
d. rationalization
Which treatment approach is most appropriate for a patient with antisocial tendencies who has been treated several times for substance addiction but has relapsed? a. One-week detoxification program b. Long-term outpatient therapy c. Twelve-step self-help program d. Residential program
d. residential program
A patient admitted yesterday for injuries sustained in a fall while intoxicated believes snakes are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury
d. risk for injury
Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg
d. systolic blood pressure: 62 mmHg
A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patients reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, We cannot see you today because youve been drinking.
d. tell the patient, We cannot see you today because youve been drinking.
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 himself or herself.
d. unable to make decisions for himself or herself
The manager of a health club put a hidden camera in the womens locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism
d. voyeurism
A new patient in an alcoholism rehabilitation program says, Im just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening. Which response by the nurse will help the patient view the drinking more honestly? a. I see, and use interested silence. b. I think you may be drinking more than you report. c. Being a social drinker involves having a drink or two once or twice a week. d. You describe drinking steadily throughout the day and evening. Am I correct?
d. you describe steadily drinking throughout the day and evening. Am I correct?
