Psych Exam 2 Practice Questions Set 1, Psych Exam 2 Practice Questions Set 4, Psych Exam 2 Practice Questions Set 2, Psych Exam 2 Practice Questions Set 3

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

ANS: A The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate. (ch 15 TB)

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. Converses without interrupting; clothing matches; participates in activities. b. Irritable, suggestible, distractible; napped for 10 minutes in afternoon. c. Attention span short; writing copious notes; intrudes in conversations. d. Heavy makeup; seductive toward staff; pressured speech.

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior. (ch 16 TB)

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: Lets go to the dining room for a snack. b. Humor: How much are you paying servants these days? c. Limit setting: You must stop ordering other patients around. d. Honest feedback: Your controlling behavior is annoying others.

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger. (ch 16 TB)

On the sixth anniversary of her spouse's death a widow says, "Sometimes life does not seem worth living anymore. I wish I could go to sleep and never wake up." Which response by the nurse has priority? a. "Are you considering suicide?" b. "You still have so much to live for." c. "Grief can sometimes last for many years." d. "Why do you continue to grieve something from long ago?"

ANS: A The nurse should always take an individual very seriously if he or she mentions some form of suicidal ideation and ask directly about suicide. (textbook ch 23, pg 362-363)

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

ANS: A The parents statements indicate denial. Denial or minimization of suicidal ideation or attempts is a defense against uncomfortable feelings. Family members are often unable to acknowledge suicidal ideation in someone close to them. The feelings suggested in the distractors are not clearly described in the scenario. (ch 23 TB)

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

ANS: A This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. (ch 23 TB)

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. Assign the child to a short time-out. b. Administer an antipsychotic medication. c. Place the child in a therapeutic hold. d. Call a staff member to seclude the child.

ANS: A Time-out is a useful strategy for interrupting the angry expression of feelings and allows the child an opportunity to exert self-control. This method is the least restrictive alternative of those listed and should be tried before resorting to more restrictive measures. (ch 26 TB)

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

ANS: A Rationalization involves unconsciously making excuses for ones behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person. (ch 11 TB)

A person who is speaking about a contender for a significant others affection says in a gushy, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a. reaction formation. b. repression. c. projection. d. denial.

ANS: A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety- producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness. (ch 11 TB)

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

ANS: A Teaching about the symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety serves to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario. (ch 11 TB)

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 childs behaviors are most consistent with: a. conduct disorder (CD). b. defiance of authority. c. anxiety over separation from a parent. d. attention deficit hyperactivity disorder (ADHD).

ANS: A The behaviors mentioned are most consistent with the DSM-5 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. (ch 26 TB)

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

ANS: B Because patients diagnosed with obsessive-compulsive disorder become overly involved in rituals, promoting involvement with other people and activities is necessary to improve the patients coping strategies. Daily activities prevent the constant focus on anxiety and its symptoms. The other interventions focus on the compulsive symptom. (ch 11 TB)

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

ANS: B Buspirone is considered effective in the long-term management of anxiety because it is not habituating. Because it is long acting, buspirone is not valuable as an as-needed or as a fast-acting medication. The fact that buspirone does not produce blood dyscrasias is less relevant in the decision to prescribe buspirone. (ch 11 TB)

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond: a. I really doubt that one person can be blamed for all the bad things that happen. b. Let's look at one bad thing that happened to see if another explanation exists. c. You are being exceptionally hard on yourself when you say those things. d. How does your belief in fate relate to your cultural heritage?

ANS: B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement. (ch 15 TB)

Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident? a. Displacement b. Rationalization c. Passive aggression d. Reaction formation

ANS: B Displacement refers to shifting feelings related to an object, person, or situation to another less threatening object, person, or situation. *Rationalization refers to justifying an action to satisfy the listener.* Passive Aggression A passive-aggressive individual deals with emotional conflict or stressors by indirectly and unassertively expressing aggression toward others. Reaction formation refers to unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating (textbook ch 11, pg 135)

A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint. (ch 24 TB)

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurses best response. a. A high proportion of patients diagnosed with bipolar disorders are found among creative writers. b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder. c. Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses. d. More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds.

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder. (ch 16 TB)

The nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? a. Mild b. Moderate c. Severe d. Panic

ANS: B In mild anxiety, clients ability to understand info may actually increase. *Moderate anxiety decreases problem solving and may hamper the clients ability to understand information. Vital signs increase somewhat and client is visibly anxious* Severe anxiety causes restlessness, decreased perception and an inability to take direction During a panic attack, the person is completely distracted, unable to function and may lose touch with reality (ATI 4)

A female nurse is appointed to a committee with seven men. At the beginning of the meeting, the chairman asks the nurse to be the secretary. The nurse responds, "No. You're just asking me to be secretary because I'm the only the woman here." Which response would have been more effective? a. "There are others more qualifed than I am to be secretary." b. "I would be glad to perform another role or our committee." c. "I'm probably overreacting, but I find your request offensive." d. "Thank you for asking, but your request is sexually discriminatory."

ANS: B In the original response, the nurse personalized the request and responded in an aggressive manner. The correct answer demonstrates an assertive response, which would have been more effective. (textbook ch 24, pg 375, pg 379)

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

ANS: A, C, D, F Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self. (ch 15 TB)

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

ANS: B Interventions should be aimed at helping the staff and patients come to terms with the loss and to grow because of the incident. Then, a community meeting should be scheduled to allow other patients to express their feelings and request help. Staff members should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. The incorrect options will not control information or may result in unsafe care. (ch 23 TB)

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithiums antimanic activity nor minimize the side effects. Lithium is used for long-term control. (ch 16 TB)

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

ANS: B Moderate anxiety causes the individual to grasp less information and reduces his or her problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem-solving abilities. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior. (ch 11 TB)

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

ANS: B Mood is a persons self-reported emotional feeling state (depressed). Affect is the emotional feeling state that is outwardly observable by others (flat). (ch 15 TB)

Which comment by a patient diagnosed with bipolar disorder best indicates the patient is experiencing mania? a. "I have been sleeping about 6 hours each night." b. "Yesterday I made 487 posts on my social network page." c. "I am having dreams about my father's death 8 years ago." d. "My appetite is so robust that I've gained 4 pounds in the past 2 weeks."

ANS: B Numerous posts on a social network page indicate hyperactivity, which is a hallmark of mania. (textbook ch 16, pg 229)

When you hear the 3-11 shift report, you learn that one of your patients was aggressive during a manic phase and restrained (wrists and ankles) in the seclusion room. Which nursing action is your top priority? A. Offer fluids, a snack, and toileting. B. Wake your patient, and assess vital signs. C. Check each extremity for circulation. D. Check the electronic medication administration record (e-MAR) for recently administered scheduled and as-needed medications. E. Assess mental status.

ANS: B Nursing actions in order of prioritization: 1. Wake your patient, and assess vital signs. 2. Check each extremity for circulation. 3. Assess mental status. 4. Check the electronic medication administration record (e-MAR) for recently administered scheduled and as-needed medications. 5. Offer fluids, a snack, and toileting. (ch 16 ppt)

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

ANS: B Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy. (ch 15 TB)

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

ANS: B Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement (ch 21 TB)

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

ANS: B Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide of a family member. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would probably not provide sufficient time to work through the issues associated with a death by suicide. (ch 23 TB)

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. intelligence. b. impulsivity. c. inattention. d. defiance.

ANS: B These behaviors demonstrate impulsivity. Intelligence refers to measurements of ones cognitive ability. Inattention is a failure to listen. Defiance is willfully doing what an authority figure has said not to do. (ch 26 TB)

When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patients behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurses presence and provides structure as necessary while the patients control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective. (ch 16 TB)

A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic. (ch 16 TB)

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

ANS: C Projection is the hallmark of blaming, scapegoating, thinking prejudicially, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. (ch 11 TB)

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? a. Male sex b. Hx of chronic bronchitis c. Recent death in client's family d. Family hx of depression e. Personal hx of panic disorder

ANS: B, C, D, E Females are twice as likely as males to experience a depressive disorder. Depressive disorders are more common in a client who has a chronic medical condition. Depressive disorders are more likely to occur in a client who is experiencing a high amount of stress (when grieving the death of a family member). Depressive disorders are more likely to occur in a client who has a family hx of depression. Hx f an anxiety or personality disorder increases a client's risk for depressive disorder. (ATI 13)

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following intervention should the nurse include in the place of care? (select all that apply) a. Provide flexible client behavior expectations b. Offer concise explanations c. Establish consistent limits d. Disregard client concerns e. Use a firm approach with communication

ANS: B, C, E Establish consistent client behavior expectations and limits to decrease client manipulation. Concise explanations improve the client's ability to focus and comprehend the information. The client's concerns should never be disregarded. Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors. (ATI 14)

What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: 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 post-traumatic stress (ch 26 TB)

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. post-traumatic stress disorder (PTSD). c. autism spectrum disorder (ASD). d. separation anxiety.

ANS: C Propranolol is useful for controlling aggression, deliberate self-injury, and temper tantrums of some children diagnosed with autism spectrum disorder. It is not indicated in any of the other disorders. (ch 26 TB)

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

ANS: C If a person has definite plans that include choosing a method of suicide readily available, and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is considered high. These areas provide a better indication of risk than the areas mentioned in the other options. (ch 23 TB)

Mrs. Chauncey, 80 years of age, complains of stomach pain and is now mute and staring out of her window. She is refusing food. Which of the following interventions are appropriate? (Select all that apply.) A. Give her privacy, and close her door. B. Speak with her, although she may not answer. C. Continue to offer her food and fluids. D. Regularly assess vital signs and skin turgor.

ANS: B, C, D Isolating Mrs. Chauncey is inappropriate. You need to be aware that older adults may experience increased depression while hospitalized. Although frail, Mrs. Chauncey may have energy to harm herself, even superficially. *Sitting with Mrs. Chauncey and speaking to her lets her know you are available.* *You are legally and ethically responsible to offer patients regular food and fluids whether they accept them or not.* *Vital signs are an important regular assessment, as well as skin turgor assessment. The older adult who is depressed is at risk for dehydration and possible hypotension.* (ch 15 ppt)

A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? a. "ECT is the recommended initial treatment for bipolar disorder." b. "ECT is contraindicated for clients who have suicidal ideation." c. "ECT is effective for clients who are experiencing severe mania." d. "ECT is prescribed to prevent relapse of bipolar disorder."

ANS: C Pharmacological intervention is the recommended initial treatment. ECT is effective for clients who have bipolar disorder and suicidal ideation. ECT is appropriate for the treatment of severe mania associated with bipolar disorder. ECT is prescribed for those experiencing an acute episode rather than for the prevention of relapse. (ATI 14)

If a cruel and abusive person rationalizes this behavior, which comment is most characteristic of this person? a. I don't know why it happens. b. I have always had poor impulse control. c. That person should not have provoked me. d. Inside I am a coward who is afraid of being hurt.

ANS: C Rationalization consists of justifying ones unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. (ch 11 TB)

A nurse is caring for a client in an inpatient mental health facility who gets up form a chair and throws it across the room. Which of the following is the priority nursing action? a. Encourage the client to express feelings out loud. b. Maintain eye contact with the client. c. Move the client away from others. d. Tell the client that the behavior is not acceptable.

ANS: C The behavior indicates that the client is at the greatest risk for harming others; the priority action for the nurse is to move the client away from others. The other options are appropriate actions however, they are not priority. (ATI 31)

Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depressive disorder with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by a military attack team d. Completion of alcohol withdrawal and beginning a rehabilitation program

ANS: C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distractors have better reality-testing ability (ch 24 TB)

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

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patients suicide as being a way to fix everything but does not say it outright. (ch 23 TB)

A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior?

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking why does not provide for environmental safety. (ch 16 TB)

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

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks, I am not going to harm myself, I am going to kill myself, or I am not going to attempt suicide, I am going to commit suicide. A patient may call a therapist and leave the telephone to carry out the suicidal plan. (ch 23 TB)

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

ANS: C The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could eat on the run. The foods in the incorrect options cannot be eaten without utensils. (ch 16 TB)

A nurse analyzes reports from four adult patients of frightening events they encountered. Which patient's report most clearly indicates that the resulting fear was mentally healthy? a. "I saw a large spider crawling along my kitchen wall." b. "I was at the mall when a gunman began firing an assault weapon." c. "I was at home when a storm with heavy thunder and lightning lasted over an hour." d. "I was trapped on an elevator that stopped between floors when the power went out."

ANS: C While all of these situations may produce some level of fear or anxiety, the correct response presents a scenario of imminent, specific danger. (textbook ch 11, pg 131)

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? a. Wide fluctuations in mood b. Report of a minimum of five clinical findings of depression c. Presence of manifestations for at least 2 years d. Inflated sense of self-esteem

ANS: C Wide fluctuations in moodier associated with bipolar disorder, rather than persistent depressive disorder. Major depressive disorder contains a minimum of five clinical findings of depression; persistent depressive disorder contains a minimum of three clinical findings. A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder. (ATI 13)

The parent of a child diagnosed with Tourettes 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 does not mean they aren't real. d. This finding is unexpected. How have you been administering your childs medication?

ANS: C Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourettes disorder. They often fluctuate in frequency and severity and are reduced or absent during sleep. (ch 26 TB)

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. (ch 26 TB)

A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, :I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should first say: a. You must come away from the door. b. You have been a widow for many years. c. You want to go home to prepare your husbands dinner? d. Was your husband angry if you did not have dinner ready on time?

ANS: C Validation therapy meets the patient where she or he is at the moment and acknowledges the patients wishes. Validation does not seek to redirect, reorient, or probe. The incorrect options do not validate the patients feelings. (ch 24 TB)

A student says, "Before taking a test, I feel a heightened sense of awareness and restlessness." The nurse can correctly assess the students experience as: a. culturally influenced. b. displacement. c. trait anxiety. d. mild anxiety.

ANS: D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. (ch 11 TB)

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

ANS: D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins. (ch 15 TB)

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? a. Set consistent limits for expected client behavior. b. Administer prescribed medications as scheduled. c. Provide the client with step-by-step instructions during hygiene activities. d. Monitor the client for escalating behavior.

ANS: D Monitoring for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action. (ATI 14)

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

ANS: D Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness. (ch 15 TB)

A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

ANS: D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patients progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Guilt and despair might be observed when the nurse experiences feelings about patients because of sympathy. Interest is possible but not the most likely result. The correct response is more global than overinvolvement. (ch 15 TB)

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (select all that apply) a. Hypotension b. Paralytic ileus c. Memory loss d. Polyuria e. Confusion

ANS: C, E Transient short-term memory loss and confusion are expected findings immediately following ECT. Paralytic ileus and polyuria are not expected findings of ECT. Hypertension, rather than hypotension, is an expected finding immediately following ECT. (ATI 10)

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

ANS: C, E Traumatic brain injury and post-traumatic stress disorder each occur in approximately 20% of soldiers returning from Afghanistan. Some soldiers have both problems. The incidence of disorders identified in the distractors would be expected to parallel the general population. (ch 23 TB)

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

ANS: C, D, E The correct questions refer to obsessive thinking and compulsive behaviors. The incorrect responses are more pertinent to a patient with suspected post-traumatic stress disorder or with suspected social anxiety disorder (social phobia). (ch 11 TB)

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

ANS: D Patients with GAD frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event. (ch 11 TB)

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? a. Children older than 5 are at greater risk b. Substance use disorder does not increase the risk for violence c. Entering an intimate relationship increases the risk for violence d. Pregnancy increases the risk for violence from a spouse or partner

ANS: D Pregnancy tends to increase the likelihood of violence from a spouse or partner (ATI 32)

A single adult says to the nurse, "Both of my parents died several years ago and my only sibling committed suicide 2 weeks ago. I feel so alone." After determining that the adult has no suicidal ideation, the nurse should: a. Explore the adult's feelings of survivor's guilt. b. Assess the adult's cultural beliefs and spirituality. c. Refer the adult for cognitive behavioral therapy (CBT). d. Refer the adult to a self-help group for suicide survivors.

ANS: D Referrals need to be made available to family members and friends to assist them in dealing with and addressing the many emotional reactions and problems that easily may develop after suicide of a family member or friend. Self-help groups are extremely beneficial for survivors. (textbook ch 23 pg 366, box 23-2)

An outpatient psychiatric nurse assesses a patient diagnosed with hoarding disorder. The patient has lost 12 pounds in the past two months, appears disheveled, and is wearing dirty clothing with poor hygiene. What is the nurse's priority action? a. Review the patient's medication regimen. b. Ask the patient, "What types of foods have you been eating?" c. Refer the patient to a psychologist or cognitive behavioral therapy (CBT). d. Schedule a home visit to assess the safety of the patient's living conditions

ANS: D Safety is the nurse's first priority. Individuals diagnosed with hoarding disorder often live in unsafe conditions. A home visit will help to identify whether safety is the primary concern. (textbook ch 11 pg 142)

Lithium is prescribed for a new patient. Which information from the patients history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function. (ch 16 TB)

When a patients aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patients affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

ANS: D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the preassaultive phase but is less effective during escalation. (ch 24 TB)

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

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. (ch 23 TB)

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "TMS is indicated for clients for have schizophrenia spectrum disorders." b. "I will provide postanesthia care following TMS." c. "TMS treatments usually last 5 to 10 minutes." d. "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks."

ANS: D TMS is commonly prescribed 3 to 5 times a week for the first 4 to 6 weeks. TMS is not indicated for the treatment of schizophrenia spectrum disorders - it is indicated for major depressive disorder that is not responsive to pharmacological treatment. ECT may be indicated for schizophrenia spectrum disorders. Clients are alert during TMS procedures and do not receive anesthesia. TMS procedure usually lasts 30 to 40 min. (ATI 10)

A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Post-trauma response c. Disturbed thought processes d. Risk for other-directed violence

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario. (ch 24 TB)

A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patients behavior shows the classic signs of someone whose potential for aggression is increasing. (ch 24 TB)

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

ANS: D The nurse helps the patient develop effective coping skills. He or she assists the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. (ch 23 TB)

Information from a patients record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. substance abuse.

ANS: D The nurse should suspect marginal coping skills in a patient with substance abuse. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence. (ch 24 TB)

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

ANS: D The patient has a highly detailed plan, a highly lethal method, the means to carry it out, lowered impulse control because of alcohol ingestion, and a low potential for rescue. (ch 23 TB)

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurses best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patients speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of cheeking the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. (ch 16 TB)

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

ANS: A A patient who is experiencing panic-level anxiety is at high risk for injury, related to an increase in nongoal-directed motor activity, distorted perceptions, and disordered thoughts. Existing data do not support the nursing diagnoses of Self-care deficit or Disturbed energy field. This patient has disturbed thought processes, but the risk for injury has a higher priority. (ch 11 TB)

The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

ANS: A At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances. (ch 16 TB)

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

ANS: A Beta-blockers, such as propranolol, are often effective in preventing symptoms of anxiety associated with social phobias. Neuroleptic medications are major tranquilizers and not useful in treating social phobias. Tricyclic antidepressants are rarely used because of their side effect profile. MAOIs are administered for depression and only by individuals who can observe the special diet required. (ch 11 TB)

What is the focus of priority nursing interventions for the period immediately after ECT treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Monitoring pupillary responses d. Assisting the patient to identify and test negative thoughts

ANS: A During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused. (ch 15 TB)

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurses most effective approach to communication. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

ANS: A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurses presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness. (ch 15 TB)

A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arms length distance from the patient. d. sit down in a chair near the patient.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patients personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurses exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patients aggression is abating. One arms length is inadequate space. (ch 24 TB)

A community mental health nurse counsels a group of patients about the upcoming flu season. What instruction does the nurse provide for patients who are prescribed lithium? a. "Stop taking your medicine and contact me if you have nausea, vomiting, and/or diarrhea." b. "Remember that lithium reduces your immunity, so you are more vulnerable to catching the flu." c. "The flu is contagious. Isolate yourself if you get the flu so that you avoid exposing others to it." d. "Because you take lithium, you may have flu symptoms that are not typically experienced by others."

ANS: A Patients should stop taking lithium if excessive diarrhea, vomiting, or sweating occurs. These problems can lead to dehydration, which can raise serum lithium to toxic levels. (textbook ch 16, pg 236, Box 16-1)

What is likely to occur when a patient taking lithium carbonate has low sodium levels? A. Lithium toxicity B. Low serum lithium levels C. Increase in mania D. Decrease in mania

ANS: A (ch 16 ppt)

A university football coach invites the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include? a. Appropriate behavior with intimate partners b. University resources or counseling and support c. The importance of role modeling for children and teens d. Public recognition of children with life-threatening illnesses

ANS: A While the nurse may include any of the topics, appropriate behaviors with intimate partners has priority. Characteristics of the game of football, the physical power required to be a player, and the risk or drug or alcohol misuse among this age group are factors that increase the risk or intimate partner violence. (textbook, Ch 21 page 338)

A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? a. Tell me about how you are feeling right now b. You should focus on the positive things in your life to decrease your anxiety c. Why do you believe you are experiencing this anxiety? d. Let's discuss the medications your provider is prescribing to decrease your anxiety.

ANS: A *Asking open-ended question is therapeutic and assists the client in identifying anxiety.* Offering advice is nontherapeutic and can hinder further communication. Why question is nontherapeutic. Postpone health teaching until after acute anxiety subsides. Clients experiencing sever anxiety are unable to concentrate or learn. (ATI 11)

Which behavior best demonstrates aggression? a. Stomping away from the nurses station, going to another room, and grabbing a snack from another patient. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, I felt angry when you said I could not have a second helping at lunch. d. Telling the medication nurse, I am not going to take that or any other medication you try to give me.

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of anothers rights. (ch 24 TB)

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patients physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury. (ch 16 TB)

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

ANS: A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and vicariously receiving gratification from the responses of others. The nurses reaction is conscious, not unconscious. No evidence of aggression is exhibited, and no evidence of conscious denial of the situation exists. Passive aggression occurs when an individual deals with emotional conflict by indirectly and unassertively expressing aggression toward others. (ch 11 TB)

Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication when the patient feels angry.

ANS: A Anger has a strong cognitive component; therefore, using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management. (ch 24 TB)

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

ANS: A Antidepressant medication has the objective of relieving depression. The risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy. (ch 23 TB)

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

ANS: A Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant. (ch 15 TB)

Rene, a restaurant manager, is hospitalized after working 15-hour days for several weeks. Her anxiety level is severe upon admission. She has not slept well during the past 2 weeks. Her psychiatrist has ordered amitriptyline (Elavil) 25 mg, to be administered orally, three times daily. Rene asks you, her nurse, why she is so drowsy. What is your best response? A. "Drowsiness is a side effect of this medication." B. "Don't worry about being drowsy at this time." C. "Aren't you glad you will finally get to sleep?" D. "I will tell the doctor. I don't want you to fall."

ANS: A Giving an anxious patient a simple and accurate answer helps the patient understand that she is experiencing something that is expected. Telling the patient not to worry diminishes her concern and does not convey interest on your part. Cliché responses are not therapeutic. Although it may be true that the patient will sleep better with this medication, this answer does not give the patient requested information. The patient is at risk for falling as a result of the sedative effects of the medication and the level of anxiety she is experiencing. Placing the patient on the unit's Falls Precautions Protocol is a critical nursing intervention. You would not notify the physician. (ch 11 ppt)

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

ANS: A Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house. (ch 11 TB)

A patient in the emergency department has no physical injuries but exhibits disorganized behavior and incoherence after minor traffic accident. In which room should the nurse place the patient? a. Interview room furnished with a desk and two chairs b. Small, empty storage room with no windows or furniture c. Room with an examining table, instrument cabinets, desk, and chair d. Nurses office, furnished with chairs, files, magazines, and bookcases

ANS: A Individuals who are experiencing severe to panic-level anxiety require a safe environment that is quiet, nonstimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurses office or a room with an examining table and instrument cabinets may be overstimulating and unsafe. (ch 11 TB)

The staff development coordinator plans to teach use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion. (ch 24 TB)

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

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self- worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept. (ch 15 TB)

Alex has a chemistry test this morning. She "crammed" for the test the previous night but did not study before that. She has an upset stomach and headache. What type of anxiety is Alex experiencing? a. Normal b. Acute c. Chronic

ANS: A Normal anxiety motivates people to make and survive change. Normal anxiety is a healthy life force necessary for survival. (ch 11 ppt)

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

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. (ch 23 TB)

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

ANS: A Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient himself or herself to a pressured work schedule is less relevant than the correct rationale. (ch 15 TB)

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

ANS: A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. The statement, "My legs feel weak most of the time," is more in keeping with a somatoform disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with post-traumatic stress disorder. (ch 11 TB)

A parent diagnosed 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 post-traumatic 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. (ch 26 TB)

A patient diagnosed with bipolar disorder lives in the community and is showing early signs of mania. The patient says, "I need to go visit my daughter but she lives across the country. I put some requests on the Internet to get a ride. I'm sure someone will take me." What is the nurse's most therapeutic response? a. "I'm concerned about your safety when meeting or riding with strangers." b. "Have you asked friends and family to donate money for your air fare?" c. "You are not likely to get a ride. Let's consider some other strategies." d. "Have you asked your daughter if she wants you to come for a visit?"

ANS: A Safety is a priority. Mania impairs the person's judgment and impulse control, which may result in harm to self. The correct response identifies potential dangers and shows care or the patient. (textbook ch 16, pg 230-231)

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

ANS: A Safety is of highest priority; the patient who is experiencing panic is at high risk for self- injury related to an increase in nongoal-directed motor activity, distorted perceptions, and disordered thoughts. The goal should be to decrease the environmental stimuli. Respecting the patients personal space is a lower priority than safety. The clarification of feelings cannot take place until the level of anxiety is lowered. (ch 11 TB)

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? a. Stop screaming and walk with me outside. b. Why are you so angry and screaming at everyone? c. You will not get your way by screaming. d. What was going through your mind when you started screaming?

ANS: A Setting limits and the use of physical activity (walking) to deescalate anger is an appropriate intervention. "Why" questions imply criticism and will often cause the client to become defensive. "You will not get your way by screaming." is a closed-ended, non-therapeutic statement. The client is not ready to discuss the issue so asking what was going through their mind is not yet appropriate. (ATI 31)

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

ANS: A Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding. (ch 15 TB)

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

ANS: A Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patients support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias. (ch 15 TB)

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information. (ch 16 TB)

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful. (ch 16 TB)

Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He asks you, "How will I ever be able to go to the beach or be with a girl with this gross bag hanging on my stomach? What is your best therapeutic response? A. "This has to be extremely difficult for you to face." B. "Don't worry about that now. Just get well!" C. "I will ask your doctor to increase your medicine." D. "If a girl really likes you, the bag won't matter."

ANS: A Stating that Charlie's condition is extremely difficult to face lets him know that you are actually listening to and thinking about what he is saying. This helps establish trust so that the conversation can possibly continue. Telling a patient not to worry implies that you do not really want to engage in meaningful and therapeutic communication. It also devalues the patient's concerns. Attributing the patient's concern strictly to medication management sidesteps the problem. Offering a cliché does not communicate to the patient that you are interested in helping solve the problem. (ch 11 ppt)

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? a. Placing the patient on one-to-one observation b. Assisting the client perform ADLs c. Encouraging the client to participate in counseling d. Teaching the client about medication adverse effects

ANS: A The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm; the highest priority intervention is placing the client on one-to-one observation. (ATI 13)

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? a. Assess the clients risk for self harm b. Instill hope for positive outcomes c. Encourage the client to participate in group therapy sessions d. Assist the client to participate in treatment decisions

ANS: A The greatest risk to a client who has an anxiety or OCD disorder is self-harm. First action to take is to access the client's risk for self-hard to ensure that the client is provided with a safe environment. (ATI 11)

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

ANS: A The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L. (ch 16 TB)

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

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. Often, patients feel relieved to be able to talk about suicidal ideation. (ch 23 TB)

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you, while twirling and shadowboxing." Then the patient says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the patients mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

ANS: A The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patients mood. A high level of suspicion is not evident. (ch 16 TB)

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

ANS: A The patient is experiencing anxiety. The nurse has closed off patient-centered communication by changing the subject. The introduction of an irrelevant topic makes the nurse feel better. The nurse may be uncomfortable dealing with the patients severe anxiety. The nurse has not responded to the patients physical needs. There is no evidence of false cognition. Focusing is a therapeutic communication technique used to concentrate attention on a single issue. (ch 11 TB)

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

ANS: A The patient now has more energy and may have decided on suicide, especially considering the history of the prior suicide attempt. The patient is still a suicide risk; therefore, continuous supervision is indicated. (ch 23 TB)

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

ANS: A The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes. (ch 21 TB)

A patient who had a stroke 3 days ago tearfully tells the nurse, "What's the use in living? I'm no good to anybody like this." Which action should the nurse employ first when caring for a patient demonstrating hopelessness? a. Implement the institutional protocol for suicide risk. b. Support the patient to clarify and express feelings of grief . c. Educate the patient about the success of stroke rehabilitation. d. Offer the patient an opportunity to confer with the pastoral counselor.

ANS: A The patient's comment suggests hopelessness, helplessness, and worthlessness. Physical illnesses play a role in increasing suicide risk. Suicide precautions should be initiated. (textbook ch 23 pg 369, Table 23-1)

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

ANS: A This intervention, a form of cognitive restructuring, replaces negative thoughts such as I cant leave my apartment with positive thoughts such as I can control my anxiety. This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role. (ch 11 TB)

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

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting the genetic load. The incorrect options are untrue statements or oversimplifications. (ch 23 TB)

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

ANS: A Up to 10% of patients diagnosed with schizophrenia die from suicide, usually related to depressive symptoms occurring in the early years of the illness. Depressive symptoms are related to suicide among patients diagnosed with schizophrenia. Patients diagnosed with schizophrenia usually have auditory, not visual, hallucinations. Although the use of drugs and alcohol compounds the risk for suicide, it is independent of schizophrenia. (ch 23 TB)

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

ANS: A, B, C One-on-one observation is necessary for anyone who has limited control over suicidal impulses. Plastic dishes on trays and the removal of potentially harmful objects from the patients possession are measures included in any level of suicide precautions. The remaining options are used in less stringent levels of suicide precautions. (ch 23 TB)

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

ANS: A, B, C The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment. (ch 15 TB)

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

ANS: A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. (ch 15 TB)

A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that staff take which actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

ANS: A, B, D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion. (ch 24 TB)

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patients sleep patterns

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania. (ch 16 TB)

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

ANS: A, B, E The child can be hypothesized to have moderate-to-severe anxiety. A calm manner calms the child. A simple, structured, predictable environment is less anxiety provoking and reduces overreaction to stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the child is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play also helps by allowing the child to act out concerns. (ch 11 TB)

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

ANS: A, B, E Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult men, adolescents, and young adults. Other high risk groups include young African-American men, Native-American men, older Asian Americans, and persons with traumatic brain injury. (ch 23 TB)

A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, theres no guarantee I won't have a relapse. I am such a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patients statements. No data support the other diagnoses. (ch 16 TB)

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

ANS: A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication. (ch 11 TB)

Because an intervention is required to control a patients aggressive behavior, a critical incident debriefing takes place. Which topics should be the focus of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggressionc. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

ANS: A, C, D The patients behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective. (ch 24 TB)

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (select all that apply) a. Conducting a suicide risk screening on all new clients b. Creating a support group for family members of clients who completed suicide c. Educating high school students about suicide prevention d. Initiating one-on-one observation for a client who has current suicidal ideation e. Teaching middle-school educators about warning indicators of suicide

ANS: A, C, E Primary interventions include suicide prevention through the use of screenings to identify individuals at risk and through the use of community education. Creating a support group for family members of clients who completed suicide is an example of a tertiary intervention. Initiating one-on-one observation for a client who has current suicidal ideation is an example of secondary intervention. (ATI 30)

A nurse is assessing a client who has major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (select all that apply) a. My family will be better off if I'm dead. b. The stress in my life is too much to handle. c. I wish my life was over. d. I don't feel like I can ever be happy again. e. If I kill myself then my problems will go away.

ANS: A, C, E The correct options are overt comments about suicide in which the client directly talks about their perception of an outcome of their death/ complete suicide or about their wish to no longer be alive. In the case that a client makes an overt comment about suicide, asses the client further for a suicide plan. The incorrect options are covert comments in which the client identifies a problem but does not directly talk about suicide; assess for suicidal ideation. (ATI 30)

Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

ANS: A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations (ch 24 TB)

Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

ANS: A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence. (ch 24 TB)

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? Select all that apply. a. Excessive worry for 6 months b. Impulsive decision making c. Delayed reflexes d. Restlessness e. Sleep disturbance

ANS: A, D, E GAD is characterized by uncontrollable, excessive worry for more than 6 months, restlessness, and/or the presence of sleep disturbances. GAD is characterized by procrastination in decision making rather than impulsive decision making and muscle tension rather than delayed reflexes. (ATI 11)

A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting. (ch 24 TB)

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

ANS: A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected. (ch 15 TB)

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (select all that apply) a. Voice changes b. Seizure activity c. Disorientation d. Cough e. Neck pain

ANS: A, D, E Vocal changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx. Cough is a potential adverse effect of VNS. Neck pain is a potential adverse effect of VNS however, this usually subsides with time. Both seizure activity and disorientation are associated with ECT rather than VNS (ATI 10)

An adult with paranoia becomes agitated and threatens to assault a staff person. Select the best initial nursing intervention. A. Tell the patient, "If you do not calm down, seclusion will be needed." B. Address the patient with simple directions and a calming voice. C. Help the patient focus by rubbing the patient's shoulders. D. Offer the patient a dose of antipsychotic medication. E. Reorient the patient to the time and place.

ANS: B (ch 24 ppt)

Mrs. H, 87, is anxious. She tells you she must go home immediately, saying: "My twins need me. They're barely a year old!" Select the best response. A. Help reorient her by explaining patiently that she is too old now to still have babies. B. Ask her questions to describe her need to go home and sympathize with how hard it can be to be away from home. C. Implement withdrawal and promise to return in 10 minutes when she is calmer and more rational. D. Reward her with attention when she focuses on reality.

ANS: B (ch 24 ppt)

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

ANS: B A SAD PERSONS scale score of 0 to 5 suggests home care with follow-up. A score of 6 to 8 requires psychiatric consultation. A score over 8 calls for hospitalization. (ch 23 TB)

Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of intimate partner violence. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

ANS: B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients diagnosed with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co- existing anger, but violence is not often demonstrated. Patients experiencing paranoid delusions are at greater risk for violence than those with bizarre somatic delusions. (ch 24 TB)

An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by two security guards and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."

ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort. The security guards are likely to intimidate the patient and increase feelings of vulnerability. (ch 24 TB)

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

ANS: B A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed. (ch 15 TB)

Charlie is 19 years old with an ileostomy caused by rectal surgery for cancer, which has rendered him sexually impotent. He is admitted to the psychiatric unit and is unable to state his name. What type of anxiety is Charlie experiencing? a. Normal b. Acute c. Chronic

ANS: B Acute anxiety is a response to stress. It is precipitated by loss or change that threatens sense of security of an individual. (ch 11 ppt)

A patient diagnosed with major depressive disorder was hospitalized for 2 weeks on an acute psychiatric unit. One day after discharge, the patient completed suicide. Recognizing likely reactions among staff, which action should the nursing supervisor implement first? a. Assess each staff member individually for suicidal intent and/or plans. b. Provide a private setting for staff members to talk about feelings associated with the event. c. Remind staff members that suicide is a risk for the patient population and they are not at fault. d. Invite a guest speaker to conduct an educational session for staff members about suicide risk factors.

ANS: B All health care members who provided care for a suicide victim, including medical staff, nursing staff, and ancillary staff, are at risk or being traumatized by suicide. Staff also may experience symptoms of posttraumatic stress disorder with guilt, shock, anger, shame, and decreased self-esteem. To reduce the trauma associated with the sudden loss, posttrauma loss debriefing can help to initiate an adaptive grief process and prevent self-defeating behaviors. (textbook ch 23, pg 365, Box 23-1)

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

ANS: B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving to begin (ch 11 TB)

A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changes

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest. (ch 16 TB)

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

ANS: B Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Vegetative symptoms refer to somatic changes associated with depression. Euphoria refers to an elated mood. Anergia means without energy. (ch 15 TB)

A priority nursing intervention for a patient diagnosed with major depressive disorder is: a. distracting the patient from self-absorption. b. carefully and inconspicuously observing the patient around the clock. c. allowing the patient to spend long periods alone in self-reflection. d. offering opportunities for the patient to assume a leadership role in the therapeutic

ANS: B Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit. (ch 15 TB)

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following response should the nurse make? a. "Why do you think you feel the need to give money away?" b. "I am here to provide care and cannot accept this from you." c. "I can request that your case manager discuss appropriate charity options with you." d. "You should know that giving away your money is inappropriate."

ANS: B Asking a "why" question is non therapeutic and can promote a defensive response. Recommending appropriate charity options does not recognize the possibility of poor judgement. Offering disapproval (option D) can be interpreted as aggressive and can promote a defensive response. (ATI 14)

When assessing a 2-year-old diagnosed with autism spectrum 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 Autism spectrum disorder involves distortions in the development of social skills and language that include perception, motor movement, attention, and reality testing. Caretakers frequently mention the childs failure to develop interpersonal skills. The distractors are more relevant to ADHD, separation anxiety, and CD. (ch 26 TB)

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? a. Insist that the client stop yelling. b. Request that other staff members remain close by. c. Move as close to the client as possible. d. Walk away from the client.

ANS: B Having other staff members remain close by is important so they can assist if necessary. The nurse shouldn't make demands of the client (insisting they stop yelling). Clients who are angry need a large personal space however, the nurse should never walk away from the client who is angry because it is the nurse's responsibility to intervene as appropriate. (ATI 31)

This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patients extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis. (ch 16 TB)

A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Administer lorazepam (Ativan) every 4 hours to reduce the patients anxiety.

ANS: B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice. (ch 24 TB)

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

ANS: B Lack of social support and social isolation increase the suicide risk. The willingness to seek help lowers the risk. Being a person of color does not suggest a higher risk; more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with a higher risk of suicide. (ch 23 TB)

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

ANS: B Lorazepam is a benzodiazepine medication used to treat anxiety; it may be administered as needed. Buspirone is long acting and not useful as an as-needed drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents (ch 11 TB)

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurses most appropriate response. a. You will be able to stop the medication in approximately 1 month. b. Taking the medication every day helps prevent relapses and recurrences. c. Usually patients take this medication for approximately 6 months after discharge. d. Its unusual that the health care provider has not already stopped your medication

ANS: B Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information. (ch 16 TB)

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients diagnosed with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume. (ch 16 TB)

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

ANS: B Patients taking MAOIs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure. (ch 15 TB)

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. You look nice this morning. b. You are wearing a new shirt. c. I like the shirt you're wearing. d. You must be feeling better today.

ANS: B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as an observation avoid negative interpretations. Saying "You look nice" or 'I like your shirt gives approval" (nontherapeutic techniques). Saying "You must be feeling better today" is an assumption, which is nontherapeutic. (ch 15 TB)

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patients condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patients treatment is completed.

ANS: B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouses presence and concerns. The incorrect options are likely to increase anger because they imply that the anxiety is inappropriate. (ch 24 TB)

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

ANS: B Providing information in a calm, simple manner helps the patient grasp the important facts. Introducing extraneous topics as described in the incorrect options will further scatter the patients attention. (ch 11 TB)

A nurse is caring for a client who smokes and has lung cancer. The client reports, " I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? a. Reaction formation b. Denial c. Displacement d. Sublimation

ANS: B Reaction formation is overcompensating for demonstrating the opposite behavior of what is felt *Denial is pretending the truth is not reality to manage the anxiety of acknowledging what is real. This patient is in denial about his lung cancer.* Displacement shifting feelings related to an object, person, or situation to another less than threatening object, person or situation Sublimation is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression (ATI 4)

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? a. Refusing to pay bills for a dependence, when when funds are available is neglect b. Intentionally causing someone to fall is an example of physical violence c. Striking a sexual partner is an example of sexual violence d. Failure to provide a stimulating environment for normal development is an emotional abuse

ANS: B Refusing to pay bills for a dependent is economic abuse. *Physical violence occurs when physical pain or harm is directed toward another individual* Striking any individual is physical abuse. Failing to provide a stimulating environment is neglect. (ATI 32)

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

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidal crises. (ch 23 TB)

A woman experienced a double mastectomy yesterday. Now she cheerfully says to the nurse, "I didn't need those things anyway. No more wet T-shirt contests or me!" How should the nurse interpret this comment? a. The patient is realistically accepting her loss. b. The comment is sarcastic, which may reflect anger. c. The patient is experiencing a distorted body image. d. The comment suggests guilt regarding prior behavior.

ANS: B Sarcasm is a veiled form of anger. (textbook ch 24, ph 375)

A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for not knowing enough to give me pain medicine when I need it. Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

ANS: B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs. (ch 24 TB)

A patient experiencing acute mania waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes." Select the nurses most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patients distractibility to the staffs advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patients need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response. (ch 16 TB)

An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurses immediate attention? a. I hate all of you! b. My fingers are tingly. c. You wait until I tell my lawyer. d. It was not my fault. The other patient started it.

ANS: B The correct response indicates impaired circulation and necessitates the nurses immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation. (ch 24 TB)

A parent tells the nurse about the death of a child 2 years ago. Which comment by this parent warrants the nurse's priority attention? a. "I still have some of my child's toys and clothes." b. "A parent should never live longer than their child." c. "I never returned to church again after the death of my child." d. "My child has been dead a long time, but it seems like only yesterday."

ANS: B The correct response represents a covert message and suggests possible suicidal thinking by the parent. The nurse should further assess the meaning of the comment. (textbook ch 23, pg 366)

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury. (ch 16 TB)

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? a. Client's educational and economic background b. Lethality of the method and availability of means c. Quality of the client's social support d. Client's insight into the reasons for the decision

ANS: B The greatest risk to the client is self-harm as a result of carrying out a suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is. (ATI 30)

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

ANS: B The nurse must assess the patients access to the means to carry out the plan and, if there is access, alert the parents to remove them from the home. The other questions may be important to ask but are not the most critical. (ch 23 TB)

A a nurse searches newly admitted patient's bag and finds nothing dangerous and is returned to the patient. The patient begins to unfold and refold his clothing slowly and repetitively. What is the nurse's best action in response to the patient? A. Immediately stop him, and tell him his behavior is inappropriate. B. Continue the interview and allow him to continue as long as he is not harming himself or others. C. Explain that his behavior is a part of his illness and that you can help him work toward change. D. Leave the room and come back later when he has stopped the behavior.

ANS: B The patient's compulsive behavior is likely triggered or worsened by anxiety as a result of his admission to the psychiatric unit. Telling him that his behavior is inappropriate (he already knows that) will only serve to increase his anxiety. *During the initial hours of his hospitalization, he needs to be allowed to continue his ritual as long as it does not pose harm to himself or others. You will need to begin to set appropriate behavior limits later.* An explanation during the admission process will probably result in increased anxiety. When he is feeling more comfortable and trusting, he may be able to invest in behavior changes. It would not be safe at this time to leave him alone. Although his current behavior is benign, his compulsive behavior indicates that his anxiety is increasing. (ch 11 ppt)

A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

ANS: B The patients threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distractors are not sufficient reasons for seclusion. (ch 24 TB)

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. Restrict oral fluids for 24 hours and stay in bed. b. Have someone bring you to the clinic immediately. c. Drink a large glass of water with 1 teaspoon of salt added. d. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patients symptoms. Restricting oral fluids will make the situation worse. (ch 16 TB)

A patient with burn injuries has had good coping skills for several weeks. Today, a new nurse is poorly organized and does not follow the patients usual schedule is. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse managers best response? a. Explain the reasons for the disorganization, and take over the patients care for the rest of the shift. b. Acknowledge and validate the patients distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patients feelings, validating them as understandable, apologizing if necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step. (ch 24 TB)

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met. (ch 16 TB)

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? Select all that apply. a. Reassure the client that everything will be ok b. Discuss prior use of copying mechanisms with the client c. Ignore the client's anxiety so that she will not be embarrassed d. Demonstrate a clam manor while using simple and clear directions e. Gather information from the client using closed ended questions

ANS: B, D Providing false reassurance is an example of nontherapeutic communication. *Discussing prior use of copying mechanisms assists client in identifying ways to effectively cope with current stressor.* Recognizing the clients current level of anxiety assists the client to begin the process of problem solving. *Providing a calm presence assists the client in feelings secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.* Using open ended, rather than closed ended, questions for client communication encourages the client to express feelings and identify the source of the anxiety (ATI 4)

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (select all that apply) a. Use caffeine in moderation to prevent relapse b. Difficulty sleeping can indicate a relapse c. Begin taking your medications as soon as a relapse begins d. Participating in psychotherapy can help prevent a relapse e. Anhedonia is a clinical manifestation of a depressive relapse

ANS: B, D, E Caffeine can precipitate a relapse. A client with bipolar disorder should take prescribed medications to prevent and minimize a relapse, not begin medications when a relapse begins. (ATI 14)

A nurse is assessing a client in an inpatient mental health unit. Which of the following should the nurse expect if the client is in the preassaultive stage of violence? (select all that apply) a. Lethargy b. Defensive responses to questions c. Disorientation d. Facial grimacing e. Agitation

ANS: B, D, E Disorientation is more likely to be assessed in a client who has a cognitive disorder. Lethargy is more likely to be observed in a client who has depression. (ATI 31)

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

ANS: C A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patients anxiety level. Using defense mechanisms does not apply. (ch 11 TB)

A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help this patient? a. Discontinue the dressing change without comments and leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice. Your doctor ordered this dressing change."

ANS: C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patients anger by belittling or escalating the patients sense of powerlessness. (ch 24 TB)

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

ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. (ch 21 TB)

An 8-year-old tells a parent, "I like to scare kids at school by showing them pictures of clowns. Some kids are terrified." How should the nurse counsel the parents regarding this behavior? a. Recommend family therapy for the child, siblings, and parents. b. Suggest the parents enroll the child in an anger management program. c. Educate both parents about bullying, including possible origins and long-term effects. d. Teach the parents about the developmental phase and tasks for an 8-year-old child.

ANS: C Bullying is an intentional display and a use of violence, though it may appear mild in some instances. Bullying can be defined as an offensive, intimidating, malicious, condescending behavior designed to humiliate. The scenario identifies an instance of lateral bullying. All kinds of bullying behaviors create a toxic environment. Those who are bullied are prone to negative feelings about self, humiliation, poor self-concept, and great emotional pain, and many can suffer severe, long-term reactions. After educating the parents about bullying, the nurse should assist them in setting limits with the child. (textbook ch 24, pg 375, pg 379)

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

ANS: C Calm, brief, directive verbal interaction can help the patient gain control of the overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus learning relaxation techniques is virtually impossible. Administering an anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other, less-restrictive measures are proven ineffective. (ch 11 TB)

Mr. Jones has not left his house for 3 months. He tells his family, "I know this is not normal, but I just can't go outside." His wife died 3 years earlier. What type of anxiety is Mr. Jones experiencing? a. Normal b. Acute c. Chronic

ANS: C Chronic anxiety is *long-term* and thought to be associated with increased risk for cardiovascular morbidity; usually begins at young age. (ch 11 ppt)

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? a. "I can expected my problems with PMDD to be worst when I'm menstruating." b. "I should avoid exercising when I am feeling depressed." c. "I am aware that my PMDD causes me to have rapid mood swings." d. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

ANS: C Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses. Aerobic and other exercise are effective treatments for depressive disorders. A clinical finding of PMDD is emotional lability; the client can experience rapid changes in mood. PMDD increases the client's risk for weigh gain due to overeating; it is not appropriate to increase caloric intake. (ATI 13)

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

ANS: C Cognitive behavioral therapy attempts to alter the patients dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned. (ch 15 TB)

A confused older adult patient in a skilled care facility is sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patients action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care workers behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

ANS: C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member. (ch 24 TB)

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy. (ch 16 TB)

Alprazolam (Xanax) is prescribed for a patient experiencing acute anxiety. Health teaching should include instructions to: a. report drowsiness. b. eat a tyramine-free diet. c. avoid alcoholic beverages. d. adjust dose and frequency based on anxiety level.

ANS: C Drinking alcohol or taking other anxiolytic medications along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration. (ch 11 TB)

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? a. Borderline personality disorder b. Acute withdrawal related to substance use disorder c. Bipolar disorder with rapid cycling d. Dysphoric disorder

ANS: C ECT is indicated for the treatment of bipolar disorder with rapid cycling. ECT has not been found to be effective for the treatment of personality disorders, substance use disorders, or dysphoric disorders. (ATI 10)

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

ANS: C Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients. (ch 15 TB)

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

ANS: C Establishing rapport will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, the lethality of a suicide plan, and the presence of risk factors for suicide. (ch 23 TB)

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

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the items, such as when a suicide plan has been formulated. Calling parents and crying do not provide clues to suicide, in and of themselves. Remaining in the dormitory would be an expected behavior because the student has nowhere else to go. (ch 23 TB)

A patient experiencing depression says to the nurse, "My health care provider said I need 'talk' therapy but I think I need a prescription for an antidepressant medication. What should I do?" Select the nurse's best response. a. "Which antidepressant medication do you think would be helpful?" b. "There are different types of talk therapy. Most patients find it beneficial." c. "Let's consider some ways to address your concerns with your health care provider." d. "Are you willing to give 'talk therapy' a try before starting an antidepressant medication?"

ANS: C Helplessness is sometimes a finding in major depressive disorder. The nurse has a responsibility for patient advocacy. Helping the patient to advocate for self is empowering. (textbook ch 15, pg 200-201)

Which behavior indicates that the treatment plan for a child diagnosed 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 parents 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 someones 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. (ch 26 TB)

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood

ANS: C Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania. (ch 16 TB)

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.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia. (ch 14 TB)

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

ANS: C Idealization is an unconscious process that occurs when an individual attributes exaggerated positive qualities to another. Denial is an unconscious process that calls for the nurse to ignore the existence of the situation. Projection operates unconsciously and results in blaming behavior. Compensation results in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point. (ch 11 TB)

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

ANS: C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarification helps the patient identify his or her thoughts and feelings. Asking the patient why he or she feels anxious is nontherapeutic, and the patient will not likely have an answer. The patient may be unable to determine what he or she would like the nurse to do to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish (ch 11 TB)

A patient is pacing the hall near the nurses station and swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. Hey, whats going on? b. Please quiet down immediately. c. I'd like to talk with you about how youre feeling right now. d. You must go to your room and try to get control of yourself.

ANS: C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patients feelings and concerns, which leads to the next step of planning an intervention. The incorrect responses are authoritarian, creating a power struggle between the patient and nurse (ch 24 TB)

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

ANS: C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals to relief anxiety. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior. (ch 11 TB)

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? a. Narcissistic behavior b. Fear of rejection from staff c. Attempt to reduce anxiety d. Adverser effect of antidepressant medication

ANS: C Narcissistic causes clients to seek admiration from others. Fear of rejection from staff might cause a client to avoid social situations and might be associated with social phobia anxiety disorder. *Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.* Clients who have OCD might take an antidepressant to help control repetitive behavior. (ATI 11)

Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

ANS: C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or borderline personality disorder. (ch 24 TB)

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

ANS: C Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure. (ch 15 TB)

A patient experiencing acute mania undresses in the group room and dances. The nurses first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach. (ch 16 TB)

A patient diagnosed with pneumonia has been hospitalized for 4 days. Family members describe the patient as a difficult person who finds fault with others. The patient verbally abuses nurses for providing poor care. The most likely explanation for this behavior lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm.

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior. (ch 24 TB)

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurses first intervention is to: a. tell the patient, "You need to be secluded." b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

ANS: C Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence. (ch 16 TB)

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

ANS: C Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes. (ch 16 TB)

Select the completion of this sentence that demonstrates an adult is coping in a healthy way: "I am feeling so angry right now... a. I'm afraid I'm going to cry." b. I would like to punch something." c. I want to talk to someone about it." d. I want to curl up and sleep or a long time."

ANS: C Talking about one's feelings is healthier than violence or avoidance. (textbook ch 24, pg 375, pg 384)

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

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have appropriate categories to provide information on the other options listed. (ch 23 TB)

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

ANS: C The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, Whats the matter with me? Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety. (ch 11 TB)

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distractors are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event. (ch 24 TB)

Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.

ANS: C The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes. (ch 16 TB)

A patient tells the nurse, "I don't go to restaurants because people might laugh at the way I eat, or I could spill food and be laughed at." The nurse assesses this behavior as consistent with: a. acrophobia. b. agoraphobia. c. social anxiety disorder (social phobia). d. Post-traumatic stress disorder (PTSD).

ANS: C The fear of a potentially embarrassing situation represents social anxiety disorder (social phobia). Acrophobia is the fear of heights. Agoraphobia is the fear of a place in the environment. Post-traumatic stress disorder is associated with a major traumatic event. (ch 11 TB)

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "Care during the continuation phase focuses on treating continued manifestations of MDD." b. "The treatment of MDD during the maintenance phase last 6 to 12 weeks." c. "The client is at greatest risk for suicide during the first weeks of an MDD episode." d. "Medication and psychotherapy are most effective during the acute phase of MDD."

ANS: C The focus of the continuation phase is relapse prevention; treatment occurs during the acute phase of MDD. The maintenance phase can last for 1 year or more. Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD. (ATI 13)

A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action. a. Educate the patient about the low odds of winning the lottery. b. Present reality by saying to the patient, "That is not good use of your money." c. Confer with the treatment team about appointing a legal guardian for the patient. d. Tell the patient, "If you buy lottery tickets, your money will run out before the end of the month."

ANS: C The nurse has responsibility for advocacy. In view of the patient's long history of problems, a legal guardian should be considered. (textbook ch 16, pg 227, pg 230-232)

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

ANS: C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing. (ch 15 TB)

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

ANS: C The patients statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to justify the other diagnoses. (ch 15 TB)

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

ANS: C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic-level anxiety demonstrates significantly disturbed behavior and may lose touch with reality. (ch 11 TB)

The nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The health care provider prescribes a low-dose antidepressant. In consideration of published warnings about use of antidepressant medications in younger patients, which action should the nurse employ? a. Notify the facility's patient advocate about the new prescription. b. Teach the adolescent about Black Box warnings associated with antidepressant medications. c. Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior. d. Remind the health care provider about warnings associated with the use of antidepressants in children and adolescents.

ANS: C The possibility that antidepressant medication might contribute to suicidal behavior, especially in children and adolescents, has been a long-time concern and all antidepressants include a black box warning; however, there is no conclusive evidence to support this concern. Use of SSRIs shows a strong association with a reduction in suicide. All treatments have potential risks; each patient should be considered individually when antidepressants are prescribed. All consumers of antidepressants should be observed carefully or worsening of depression and suicidal thoughts. (textbook ch 15, pg 211)

A 28-year-old second-grade teacher is diagnosed with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combination of factors in this scenario best demonstrates the stress-diathesis model? a. Cold climate coupled with history of abuse b. Current age of 28 coupled with family history of depression c. Family history of mental illness coupled with history of abuse d. Female gender coupled with the stressful profession of teaching

ANS: C The stress-diathesis model explains depression from an environmental, interpersonal, and life events perspective combined with biological vulnerability or predisposition (diathesis). Psychosocial stressors and interpersonal events, such as abuse, trigger certain neurophysical and neurochemical changes in the brain. Early life trauma is a significant component in the stress reaction. (textbook ch 15, pg 199-200)

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs (ch 16 TB)

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Ineffective management of the therapeutic regimen

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore higher in priority than the other options. (ch 23 TB)

Statistically speaking, which two patients do you predict are at greatest risk for suicide? (select two that apply) A. Ms. R, a 22-year-old grad student who is engaged B. Mr. M, a 34-year-old male with multiple sclerosis C. Mr. A, a 68-year-old Vietnam veteran with TBI D. Ms. G, a 25-year-old single Navajo mother who struggles with alcohol

ANS: C, D Although every patient who presents with possible suicidal ideation should be assessed equally, there may be additional risks for (a) veterans, especially with TBI (special risks); (b) older men (4 times as likely); (c) young American Indian adults (2.5 times more likely than their peers); and (d) those with mood disorders, (50%) and those who abuse alcohol (25%). (ch 23 ppt)

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

ANS: C, D, E Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations. (ch 15 TB)

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

ANS: C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The inability to contact parents can be seen as a recent lack of social support, as can the roommates absence from the dormitory. Terminating access to ones social networking site represents self-imposed isolation. This scenario does not provide data regarding a history of an earlier suicide attempt, a family history of suicide, or of co-occurring medical illness. (ch 23 TB)

A nurse prepares the plan of care for a 15-year-old adolescent diagnosed with moderate intellectual developmental disorder (IDD). What are the highest outcomes that are realistic for this person? (Select all that apply.) Within 5 years, the person will: 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. (ch 26 TB)

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

ANS: D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point. (ch 15 TB)

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? a. I wish you would not take me angry b. I feel angry when you leave me c. It makes me angry when you interrupt me d. You'd better listen to me

ANS: D "You'd better listen to me" implies a threat and a lack of respect for another individual. (ATI 31)

A patient has committed suicide while under team care in your facility. A coworker says, "Why are we being called to a 'postmortem' meeting? We didn't do anything wrong." Which is your best explanation? A. There is almost always litigation after an inhouse suicide, and it only makes sense that someone must be held responsible. B. Staff are at high-risk for hurting themselves after a suicide. C. It's important that the entire team collaborate to make documentation say the right things. D. A postmortem assessment can help the team determine any changes that might be made in agency protocol to improve safety.

ANS: D (ch 23 ppt)

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following clinical statements indicates understanding of the teaching? a. "It is common to treat depression with ECT before trying medications." b. "I can have my depression cured if I receive a series of ECT treatments." c. "I should receive ECT once a week for 6 weeks." d. "I will receive a muscle relaxant to protect me from injury during ECT."

ANS: D A muscle relaxant (succinylcholine) is administered to reduce the risk of injury during induced seizure activity. ECT is usually indicated when client's with major depressive disorder are not responsive to pharmacological treatment. ECT does not cure depression. The typical course of ECT treatment is 2-3 times a week for a total of 6-12 treatments. (ATI 10)

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

ANS: D A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks. Acting out refers to behavioral expression of conflict. Projection is a form of blaming. Suppression is the conscious denial of a disturbing situation or feeling. (ch 11 TB)

A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One- on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proved successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness. (ch 16 TB)

Mr. Q is dancing under the overhead television of the crisis stabilization unit and taunting the other patients in the room. He shouts, "I own the TV networks, so they have to do what I say!" As Mr. Q's nurse, what is your best initial intervention at this time? A. Leave him alone, and remove the other patients. B. Tell Mr. Q that he has to obey the rules, or he will be restrained. C. Medicate Mr. Q with an anxiolytic agent, and place him in seclusion. D. Calmly motion for Mr. Q to come with you to the dining room for a snack.

ANS: D A. Leaving the patient alone is not safe, and other patients need to know that their rights and well-being are also important. B. Threatening a patient with restraints is not appropriate. C. Although Mr. Quang may need both an as-needed medication and seclusion, these are not the best initial responses. *D. Distraction is the best initial intervention. Accompanying the patient to a place away from the other patients is appropriate.* (ch 16 ppt)

A parent diagnosed 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 nurses best suggestion to the treatment team? a. Suggest foster home placement. b. Seek assistance from an intimate partner 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. (ch 26 TB)

Mrs. Chauncey receives a visit from her priest. He runs out of her room and then pulls the nurse assistant back into her room. Mrs. Chauncey is cutting her left wrist (superficially) with the 5 x 7 glass from a framed photo of a grandchild. She is taken to the emergency department, where her wrist is bandaged. Her daughter and son-in-law are notified. As her nurse, which of the following statements help clarify what has taken place? A. "Don't worry, I think your mom is just confused." B. "Your mom has been more withdrawn over the last few days." C. "I am very concerned that your mom is suicidal." D. "When your mom's priest arrived, he found her cutting her wrist with the glass from a framed photo."

ANS: D A. This statement offers false reassurance. B. Although true, this statement does not give the family a clear picture of the events. C. You may suspect suicidal ideation, but until Mrs. Chauncey is further assessed, you should not state your suspicions. *D. This statement is a clear representation of what has actually happened. Once the family members understand this, then dialog related to care options can begin.* (ch 15 ppt)

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

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues. (ch 15 TB)

Select the best example of altruism. a. After recovering from a gunshot wound, a police officer attends a local support group. b. After recovering from open heart surgery, an individual plays tennis three times a week. c. An individual who received a liver transplant volunteers at a local organ procurement agency. d. An individual with a long-standing fear of animals volunteers at a community animal shelter.

ANS: D Altruism is a health defense mechanism in which emotional conflicts and stressors are addressed by meeting the needs of others. With altruism, the person receives gratification either vicariously or from the response of others. (textbook ch 11, pg 133-134)

Mrs. Chauncey, 80 years old, is taking a selective serotonin reuptake inhibitor (SSRI) and Tylenol PM daily plus other medications. She has multiple, vague somatic complaints. This morning she complains of a "stomach ache" and "gas." What is your best initial nursing response? A. Tell her to increase her water intake. B. Perform a digital rectal examination for impaction. C. Document the complaint of abdominal pain. D. Assess bowel sounds in all four quadrants.

ANS: D An increase in water intake may be an excellent intervention for an older patient as long as no fluids are restricted and no swallowing problems are evident. A digital rectal examination without further assessment is inappropriate and can be traumatic for the patient. Documenting a patient's complaint is appropriate as long as the intervention and evaluation are also completed and documented. *Assessing bowel sounds is the best initial response. Older adults are at risk for constipation, and some medications can cause constipation. Mrs. Chauncey is taking an SSRI and Tylenol PM, which contains diphenhydramine.* (ch 15 ppt)

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

ANS: D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves a graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of undesirable stimuli in an effort to extinguish the anxiety response. (ch 11 TB)

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a. repression. b. devaluation. c. identification. d. compensation.

ANS: D Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others. (ch 11 TB)

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

ANS: D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes ones own unacceptable thoughts or feelings to another. (ch 11 TB)

A community mental health nurse talks with a 6-year-old child whose divorced parents have shared custody. Which initial question will best help the nurse explore the child's perception of home life? a. "Is your life different from your friends' lives?" b. "Are you happiest at your mother's or your father's house?" c. "Do you find it hard to move back and forth between two homes?" d. "What are some of the good and bad things about living in two places?"

ANS: D Developmental level is an important part of the assessment with children, so the nurse should select terms the child will understand. A semistructured interview provides an opportunity for the child to express perceptions about life at home and life at school with teachers and peers. Severe marital discord is a factor that may contribute to mental illness in children. (textbook, Ch 26 pg 406-407)

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Discuss new relaxation techniques b. Show the client how to change the behavior c. Distract the client with a TV show d. Stay with the client and remain calm.

ANS: D During a panic attack, the client is unable to concentrate on learning new info. During panic attack, avoid further stimuli that can increase the client's level of anxiety. *Quietly remain with the client. This promotes safety and reassurance without additional stimuli.* (ATI 11)

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patients family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

ANS: D During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation. (ch 16 TB)

Over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family that electroconvulsive therapy (ECT) is needed. The family whispers to the nurse, "Isn't this a dangerous treatment?" How should the nurse reply? a. "Our facility has an excellent record of safety associated with use of ECT." b. "Your family member will eventually be successful with suicide if aggressive measures are not promptly taken." c. "Yes, there are hazards with ECT. You should discuss these concerns with the health care provider." d. "ECT is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks."

ANS: D Electroconvulsive therapy (ECT) is safe and effective and can achieve a 70% to 90% remission rate in depressed patients within 1 to 2 weeks. ECT is especially indicated when there is a need or a rapid, definitive response when a patient is suicidal or homicidal as well as in selected other circumstances. (textbook ch 15, pg 218)

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? a. Assign the client to a private room b. Document the client's behavior every hour c. Allow the client to keep perfume in her room d. Ensure that the client swallows medication

ANS: D Ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed the prescribed dose. Client's behavior should be documented every 15 min or according to facility policy. Clients who are suicidal should not be assigned a private room, nor should they have perfume in their room. (ATI 30)

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

ANS: D High-risk factors include being an older adult, single, and male and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African-American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. (ch 23 TB)

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

ANS: D Hopelessness is the characteristic common among people who attempt suicide. The incorrect options reflect myths about suicide. Not all who attempt suicide are intent on dying. Not all are mentally ill or cognitively impaired. (ch 23 TB)

A patient tells the nurse, "No matter what I do, I feel like there's always a dark cloud following me." Select the nurse's initial action. a. Assess the patient's current sleep and eating patterns. b. Explain to the patient, "Everyone feels down from time to time." c. Suggest alternative activities for times when the patient feels depressed. d. Say to the patient, "Tell me more about what you mean by 'a dark cloud'."

ANS: D The correct response accomplishes two results: the nurse can further assess the patient's complaint and the nurse uses clarification, a therapeutic communication technique. (textbook ch 15, pg 198, Table 15-1)

A patient was diagnosed with bipolar disorder many years ago. The patient tells the nurse, "When I have a manic episode, there's always a feeling of gloom behind it and I know I will soon be totally depressed." What is the nurse's best response? a. "Most patients diagnosed with bipolar disorder report the same types of feelings." b. "Feelings of gloom associated with depression result from serotonin dysregulation." c. "If you take your medication as it is prescribed, you will not have those experiences." d. "Your comment indicates you have an understanding and insight about your disorder."

ANS: D The correct response shows use of the therapeutic communication technique of verbalizing the implied. Gaining insight contributes to relapse prevention. (textbook ch 16, pg 239, Box 16-2)

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

ANS: D The safety needs of the patient and other patients are a priority. The patient is less likely to cause self-harm or hurt others when several staff members take responsibility for providing limits. The explanation given to the patient should be simple and neutral. Simply being told that others can help provide the control that has been lost may be sufficient to help the patient regain control. Running after the patient will increase the patients anxiety. More than one staff member is needed to provide physical limits if they become necessary. Asking the patient to give an example is futile; a patient in panic processes information poorly. (ch 11 TB)

A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructor's best response. a. "Other students get caught as well." b. "I am not trying to cause you to fail. I am here to help you." c. "I am sorry you feel that way. I try to treat all my students equally." d. "The requirements for this experience were discussed during our orientation."

ANS: D The student is demonstrating projection, as evidenced by not taking responsibility or his or her own behavior and blaming the instructor for a perception of failing. In the correct answer, the instructor avoids a defensive response and reinforces that responsibility belongs to the student. (textbook ch 11, pg 136-137)

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? a. A client's verbal threat of suicide is attention-seeking behavior b. Interventions are ineffective for clients who really want to commit suicide c. Using the term suicide increases the client's risk for a suicide attempt d. A no-suicide contract decreases the client's risk for suicide

ANS: D The use of a no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and client. However, it should not replace other suicide prevention strategies. The incorrect options are myths about suicide. (ATI 30)

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

ANS: D This response gives the patient reinforcement and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as, "You have a lot to live for." It uses the patients ambivalence and sets the stage for more realistic problem-solving strategies. (ch 23 TB)

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

ANS: D When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority. (ch 15 TB)

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

ANS: D When a patient seeks to have precautions lifted by professing to feel better, the patient may be seeking greater freedom in which to attempt suicide. Changing the treatment plan requires careful evaluation of outcome indicators by the staff. The incorrect options will not cause the patient to admit to a suicidal plan, do not convey concern for the patient, or suggest that the patient is not a partner in the care process. (ch 23 TB)

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

ANS: D When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive. (ch 15 TB)

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? Select all that appy a. Amenorrhea b. Hypokalemia c. Yellowing of the skin d. Slightly elevated body weight e. Presence of lanugoon the face

ANS: b, d #1: expected finding of anorexia #2 *expected finding of purging type bulimia* #3 expected finding of anorexia #4 *Most clients who have bulimia maintain a weight within a normal range or slightly higher* #5 expected finding of anorexia (ATI 19)

A nurse is planning care for a client who has anorexia nervosa with binge-eating purging behavior. Which of the following actions should the nurse include in the client's plan of care? a. Allow the client to select preferred meal times b. Establish consequences of purging behavior c. Provide the client with a high-far diet at the start of treatment d. Implement one-to-one observation during meal times

ANS: d #1 Provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia #2 Use positive approach to client care that includes rewards rather than consequences #3 Limit high-fat and gas-producing foods at the start of treatment #4 *closely monitor the client during and after meals to prevent purging* (ATI 19)

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

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the hearts capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications. (ch 14 TB)

What is a nurses legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the childs teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

ANS: B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded. (ch 21 TB)

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

ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive. (ch 21 TB)

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.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority. The question calls for an intervention rather than an assessment. (ch 14 TB)

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.

ANS: B One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private. (ch 14 TB)

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 adolescents 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. (ch 26 TB)

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

ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence. (ch 21 TB)

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

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range. (ch 14 TB)

A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? a. Your actions had nothing to do with what happened b. You should focus on recovery rather than blaming yourself for what happened. c. You believe this wouldn't have happened if you hadn't been out alone? d. Why do you feel that you should not have been alone on the street at night?

ANS C #1: this response offers the nurses's opinion, which is nontherapeutic #2 This response indicates disapproval, which is nontherapeutic #3: *this response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings* #4: nontherapeutic response (ATI 33)

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? a. Genitourinary soreness b. Difficulties with low self esteem c. Sleep disturbances d. Emotional outburst e. Difficulty making decisions

ANS D, E #1: Genirourinary soreness indicates a somatic reaction #2: difficulties with low self esteem are an indication of a sustained and maladaptive emotional response beyond the initial reaction #3: Sleep disturbances indicates a somatic reaction #4: *emotional outburst indicate an expressed initial reaction of rape-trauma syndrome* #5 *indicates a controlled initial reaction* (ATI 33)

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? a. Life isn't worth living if I gain weight b. Don't pretend like you don't know how fat I am. c. If i could be skinny, I know I'd be popular d. When I look in the mirror, I see myself as obese.

ANS: A #1 *This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition* #2 reflects personalization #3 reflects over-generalization #4 Reflects perception of distorted body image commonly experience by the client who has anorexia nervosa (ATI 19)

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? a. I will administer prophylactic treatment or STD's, like chlamydia b. I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence c. I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder d. I should use narrative documentation when documenting subjective data

ANS: A #1 Administer prophylactic treatment for infections according to CDC #2 Always obtain informed consent #3: manifestations of rape-trauma syndrome are similar to PTSD, not bipolar #4: Document subjective data, using the client's verbatim statements (ATI 33)

The parent of an adolescent recently diagnosed with schizophrenia says to the nurse, "This is entirely my fault. I should have spent more time with my child when he was a toddler." Which response by the nurse is correct? a. "Schizophrenia is genetically transmitted, so it was not in your control." b. "Your child's disorder is more likely the result of an undetected head injury." c. "Environmental toxins are directly implicated in the origins of schizophrenia." d. "Lack of prenatal care causes schizophrenia rather than early childhood events."

ANS: A Genetic factors have been implicated in a number of childhood mental disorders, including autism, bipolar disorders, schizophrenia, ADHD, intellectual developmental disorders, and some others. (textbook, Ch 26 pg 406)

Shortly after an adolescents 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 adolescents response to family stress and discord. Adolescents value peer interactions, and yet this child has eliminated that source of support. The distractors are not supported by the data in this scenario. (ch 26 TB)

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

ANS: A Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse. (ch 21 TB)

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.

ANS: A Patients diagnosed with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually disclose perceptions about self to others. The patient with anorexia will persist in trying to lose more weight. (ch 14 TB)

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 don't pay much attention to me. c. I'm thin for my height. d. I have nice eyes.

ANS: A Patients with eating disorders have distorted body images and cognitive distortions. They see themselves as overweight even when their weight is subnormal. Im thin for my height is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as I have nice eyes. Many patients with eating disorders see supportive others as intrusive and out of tune with their needs. (ch 14 TB)

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

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg. (ch 14 TB)

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

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia. (ch 14 TB)

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 depressive disorder 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 parents depression means it has been a consistent stressor. The other factors do not create ongoing stress. (ch 26 TB)

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

ANS: A The BMI value indicates extreme malnutrition. Cachexia is a hallmark of this problem; cachexia is defined as weakness and wasting of the body due to severe chronic illness. The patient would be expected to have leukopenia rather than leukocytosis. Hypothermia and hypotension are likely assessment findings. (ch 14 TB)

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

ANS: A The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the childs statements. (ch 21 TB)

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

ANS: A The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence. (ch 21 TB)

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

ANS: A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring. (ch 21 TB)

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? a. Advise the client about the location of safe houses and shelters b. Encourage the client to participate in a support group for survivors of abuse c. Implement case management to coordinate community and social services d. Educate the client about the use of stress management techniques

ANS: A The greatest risk to this client is injury from further abuse, priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live (ATI 32)

A 16-year-old adolescent diagnosed with conduct disorder (CD) has been in a residential program for three 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. (ch 26 TB)

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 impulse control, 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 control impulses and problem solve by using adaptive behaviors to meet lifes 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. (ch 26 TB)

An older adult diagnosed with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adults daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority. (ch 21 TB)

A child diagnosed 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. (ch 26 TB)

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

ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no. (ch 21 TB)

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

ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time. (ch 21 TB)

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? (Select all that apply) a. What is your relationship like with you family? b. Why do you want to lose weight? c. Would you describe your current eating habits? d. At what weight do you believe you will look better? e. Can you discuss your feelings about your appearance?

ANS: A, C #1 *A nursing history of a client who has anorexia nervosa should be include an assessment of family and interpersonal relationships* #2 Asking a why questions promotes defensive client response and is nontherapeutic #3 *A nursing history needs to include current eating habits* #4 This question promotes cognitive distortion, places the focus on weight and implies that the client's current appearance is not acceptable #5 A nursing history of a client who has anorexia should include an assessment of the client's perception of the issue (ATI 19)

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

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia. (ch 14 TB)

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

ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult. (ch 21 TB)

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? a. Rape is a crime of passion b. Acquaintance rape often involves alcohol c. Young adults are the typical victims of sexual assault d. The majority of rapists are unknown to the victims

ANS: B *Alcohol and other substances are often associated with date or acquaintance rape* Rape is a crime of violence, aggression, anger, and power. Individuals of all ages are affected by sexual assault. The majority of perpetrators are known to victims. (ATI 33)

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

ANS: B A child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present. (ch 21 TB)

Apatient 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.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that the patients needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment. (ch 14 TB)

The school nurse assess four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity? a. 5'2" tall; weight 104 pounds b. 5'7" tall; weight 110 pounds c. 5'5" tall; weight 114 pounds d. 5'8" tall; weight 127 pounds

ANS: B Body mass index (BMI) is used to gauge the level of severity, degree of functional disability, and need for supervision or persons diagnosed with anorexia nervosa. BMI is calculated as weight in kilograms divided by height in meters squared. Ideal BMIs are between 19 and 25. A person whose BMI is over or equal to 17 kg/m2 meets one criterion or anorexia nervosa with mild severity. The BMI for the correct response is 17.2. (textbook, Ch 14 Pages 184, 186)

Which scenario presents the highest risk for a pregnancy resulting in offspring with an intellectual developmental disability (IDD)? a. 18-year-old mother who received no prenatal care b. 32-year-old woman diagnosed with anorexia nervosa c. 26-year-old father with a history of episodic alcohol abuse d. 38-year-old father diagnosed with generalized anxiety disorder

ANS: B Causes of intellectual developmental disability may be a result of hereditary factors, alterations in early embryonic development, pregnancy and perinatal problems, and other actors such as trauma and poisoning. (textbook, Ch 26 pg 407)

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.

ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patients feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention. (ch 14 TB)

A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

ANS: B In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion. (ch 21 TB)

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

ANS: B Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. (ch 21 TB)

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

ANS: B Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. Pica refers to eating nonfood items. (ch 14 TB)

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

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients diagnosed with eating disorders. The incorrect options are rare in a patient with anorexia nervosa. Inflexibility, controlled emotions, and pessimism are more the norm. (ch 14 TB)

After treatment for a detached retina, a victim of intimate partner violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partners physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

ANS: B Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patients use of defense mechanisms. (ch 21 TB)

An ED nurse assesses a child with a fractured ulna. The nurse also observes yellow and purple bruises across the child's back and shoulders. Which comment by the parents should prompt the nurse to consider making a report to Child Protective Services? a. "We do not believe in immunization of our children." b. "This child is always creating problems for the family." c. "Our child would rather play alone than with other children." d. "We homeschool our children in order to include religious education."

ANS: B The acute injury, coupled with bruises of different ages, suggest that the child may be abused. Abusive parents may perceive the child as bad or evil or project blame. The nurse is required to report suspicions of abuse to child protective services. Page 344 (Box 21-3). (textbook, Ch 21)

A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: He beat me last night but then said he was sorry." Which event would the nurse expect to occur next in this relationship? a. Another beating by the abusive partner b. Love, gifts, and praise from the abusive partner c. A brief period during which the partners ignore each other d. The abusive partner leaves the relationship or a short time

ANS: B The cycle of violence consists of three phases: (1) tension-building phase, (2) acute battering phase, and (3) honeymoon phase. The question scenario shows acute battering, so a period of loving calm is likely to follow. Page 340 (Figure 21-1). (textbook, Ch 21)

A child diagnosed 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 childs hyperactivity, distractibility, and play. The incorrect options are more relevant for a child with a developmental or anxiety disorder. (ch 26 TB)

An ED nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding most clearly confirms the suspicion? a. Leathery facial tone b. Injuries in a bikini pattern c. Reluctance to be examined d. Lack of eye contact with the nurse

ANS: B The majority of the victims of reported intimate partner violence are women. Intimate partner violence is the number one cause of emergency department visits by women. Patterns of damage are often in locations that cannot be noticed easily, such as the torso, back, upper arms, upper legs, inside body orifices, and under the hair. Page 325 (Box 21-1). (textbook, Ch 21)

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 patients feelings. d. Help the patient balance energy expenditure and caloric intake.

ANS: B The nursing intervention of observing for adverse effects of re-feeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention. (ch 14 TB)

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

ANS: B The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months. (ch 21 TB)

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

ANS: B The patients child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their 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. (ch 21 TB)

A nurse plans to lead a group in a residential facility for kindergarten-aged, abused children. Which strategy should the nurse incorporate? a. Building a house using blocks b. Telling a story about a child who felt sad c. Drawing pictures of fun activities at a park d. Reading and discussing a book about abused children

ANS: B Therapeutic interventions should be matched to the developmental level of the child. Abused children are likely to have problems with anxiety or depression. Storytelling is a form of bibliotherapy likely to appeal to kindergarten-aged children. Children unconsciously identify with the characters in the story, allowing self-expression in a safe environment to occur. (textbook, Ch 26 Page 414)

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? Select all that apply. a. Sunken fontanels b. Respiratory distress c. Retinal hemorrhage d. Altered level of consciousness e. Increase in head circumference

ANS: B, C, D, E Bulging, rather than sunken, fontanels are expected (ATI 32)

A nurse working in an emergency department is assessing a preschool aged child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? Select all that apply. a. Abrasions on knees b. Round burn marks on forearms c. Mismatched clothing d. Abdominal rebound tenderness e. Areas of ecchymosis on torso

ANS: B, E #1 Minor injuries (abrasions) on arms and legs are common for this age group #2 *indicate cigarette burns* #3 mismatch clothing is consistent with child's need for independence at this age #4: Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse #5 *Areas of ecchymosis on torso, back or buttocks should alert the nurse to possible abuse* (ATI 32)

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? a. Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet. b. Instead of worrying about your weight, try to focus on other problems at this time. c . I understand you have concerns about your weight, but first, let's talk about your recent accomplishments d. You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you.

ANS: C #1: this statement minimizes and generalizes the client's concern and is therefor a non therapeutic response #2 minimizes the clients concern and is a non therapeutic response #3 *acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self-esteem and self-image* #4 minimizes the clients concern and is a non therapeutic response (ATI 19)

A patient who is referred to the eating disorders clinic has lost 35 pounds in the past 3 months. To assess the patients 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?

ANS: C Although all the questions might be appropriate to ask, only What do you eat in a typical day? focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patients thoughts on present weight explores the patients feelings about weight. (ch 14 TB)

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 cant manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescents 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 (5th edition) (DSM-5) identifies CDs as serious violations of rules. The patients clinical manifestations do not coincide with the other disorders listed. (ch 26 TB)

Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? a. "You need to gain weight to become healthier." b. "Your world would not change if you gained a few pounds." c. "Tell me how your world would be different i you were fat." d. "Your attractiveness is not defined by a number on the scales."

ANS: C Cognitive distortions with underlying emotions of anxiety, dysphoria, low self-esteem, and feeling lack of control are often present in persons suffering with eating disorders. In this instance, the adolescent is catastrophizing. The nurse should first help the patient to identify the fears. Cognitive distortions are consistently confronted by all members o the interdisciplinary team in preparation for carefully planned challenges to the patient later in treatment. (textbook, Ch 14 Page 187, Box 14-4)

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

ANS: C Examples of emotional abuse include having an adult demean a childs worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse. (ch 21 TB)

An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurses priority question? a. Do you drink excessively? b. Did your partner beat you? c. How did this happen to you? d. What did you do to deserve this?

ANS: C Obtaining the persons explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected. (ch 21 TB)

The nurse interviews the parent of a 7-year-old child diagnosed with moderate autism spectrum disorder. Which comment from the parent best describes autistic behavior? a. "My child occasionally has temper tantrums." b. "Sometimes my child wakes up with nightmares." c. "My child swings for hours on our backyard gym set." d. "Toilet training was more difficult for this child than my other children."

ANS: C Prominent behavioral characteristics of autism spectrum disorder include motions repeated over and over (flaps hands, rocks body, spins self in circles, repeatedly turns light on and off), playing with toys the same way every time, getting upset by minor changes (changes furniture around, changes route going someplace familiar), and obsessive interests. (textbook, Ch 26 Page 408)

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: C The assessment of physical abuse is supported by the nurses 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. (ch 21 TB)

While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? a. Report the clinical observation to the nursing supervisor. b. Ask the psychiatric technician, "What did you mean by that comment?" c. Privately discuss the importance of sensitivity with the psychiatric technician. d. Immediately interrupt the interaction between the patient and psychiatric technician

ANS: C The comment by the psychiatric technician trivializes the patients' problems. Low self-esteem and self-doubts about personal worth are characteristic features of persons who have eating disorders. The comment contributes to these aspects of self-perception. (textbook, Ch 14, Pages 183-184, 186)

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

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered. (ch 14 TB)

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage. (ch 21 TB)

Shortly after a 15-year-olds 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 adolescents feelings. c. Assist the adolescent to differentiate reality from perceptions. d. Assess and document the adolescents level of depression daily.

ANS: C The patients 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. (ch 26 TB)

A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? a. "I look good because whenever I overeat, I purge myself." b. "I love sweets. I make myself throw up so I can eat more." c. "I've lost 60 pounds but I'm still a size 2. I want to be a size 0." d. "I've hidden my eating disorder from everyone, even my parents."

ANS: C Thought processes that accompany anorexia nervosa include a terror of gaining weight, viewing oneself as fat even when emaciated, and judging one's self-worth by one's weight or size. (textbook, Ch 14 Page 187, Table 14-1)

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

ANS: C, D, E Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patients eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance. (ch 14 TB)

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. You'll lose more weight. c. Let's discuss the relationship between exercise and weight loss and how that affects your body. d. According to our agreement, no exercising is permitted until you have gained a specific amount of weight.

ANS: D A matter-of-fact statement that the nurses perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors. (ch 14 TB)

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.

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis. (ch 14 TB)

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

ANS: D Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary. (ch 21 TB)

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.

ANS: D Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients concentration and attention is important, but not the primary purpose of the schedule. (ch 14 TB)

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 teenagers 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. (ch 26 TB)

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 then 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. (ch 26 TB)

The nurse assessed an elderly person who was abused by the caregiver. Afterward, which internal dialogue should prompt the nurse to seek guidance? a. "Sometimes I get so discouraged and frustrated with my job." b. "It's incredible that anyone could hurt a child or elderly person." c. "The abuser was probably a victim of abuse at some point in life." d. "I hope the abuser gets victimized so they know what it feels like."

ANS: D Nurses must be self-aware, particularly in highly charged situations. Wishing harm on an abuser may be understandable, but it is an indicator of the nurse's need or guidance. (textbook, Ch 21 Page 342)

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.

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority. (ch 14 TB)

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

ANS: D Re-feeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the re-feeding syndrome. (ch 14 TB)

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 nurses 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 professional.

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 childs fear that something will happen to the attachment figure. The child needs professional help. (ch 26 TB)

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. (ch 26 TB)

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.

ANS: D The correct response is the only strategy that attempts to question the patients distorted thinking. (ch 14 TB)

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 childs most likely problem? a. Tic disorder b. Oppositional defiant disorder (ODD) c. Intellectual development disorder (IDD) d. Attention deficit hyperactivity disorder (ADHD)

ANS: D The excessive motion, distractibility, and excessive talkativeness suggest ADHD. Tic disorder is associated with stereotypical, rapid, and involuntary motor movements. Developmental delays would be observed if intellectual development disorder was present. ODD includes serious violations of the rights of others. (ch 26 TB)

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

ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options. (ch 21 TB)

A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mg/dL Phosphate 3.0 mg/dL The nurse should take which action next? a. Measure the patient's body temperature. b. Inspect the patient's skin and sclera or jaundice. c. Assess the patient's mucous membranes or erosion. d. Auscultate the patient's heart rate, rhythm, and sounds.

ANS: D The laboratory results show hypokalemia and hypocalcemia, which is likely to affect cardiac function, producing bradycardia, arrhythmias, and/or murmurs. (textbook, Ch 14 Page 185, Box 14-2)

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.

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable. (ch 14 TB)

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

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa (ch 14 TB)

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

ANS: D The patients history and laboratory results support the correct nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia. (ch 14 TB)

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

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patients self-starvation is the priority above the incorrect responses. (ch 14 TB)

A 5-year-old child diagnosed 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 nurses 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 incorrect options provide no outlet for feelings or opportunity to develop coping skills. (ch 26 TB)