117 Possible Exam Questions Finals

Document the observation

• Shortly after admission an adolescent falls to the floor and has tonic-clonic movements. There is no verbal response, but a nurse observes that the client is still chewing gum. What should the nurse do next? o Document the observation o Insert a tongue blade between the teeth Remove the chewing gumoSend another client for help

Headache, Dyspepsia, Flushing

• Sildenafil is prescribed for a man experiencing erectile dysfunction. A nurse teaches the client about which common side effects of this drug? SELECT ALL THAT APPLY o Constipation o Headache o Dyspepsia o Hypertension o Flushing

A Stay physically close to the client

A client comes to a mental health center with severe anxiety evidenced by crying, wringing the hands, and pacing. What should be the first nursing intervention? o Involve the client in a nonthreatening activity o Stay physically close to the client o Tell the client to try to relax by sitting quietly o Gently ask what is bothering the client

Feelings of panic

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to end this feeling." What clinical manifestation is evident? o Passive personality o Narcissistic ideation o Suicidal tendencies o Feelings of panic

Correcting electrolyte imbalances

A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. Which is a priority when a nurse plans for this client? o Controlling impulsive behaviors o Developing a contract for treatment goals o Identifying personal strengths o Correcting electrolyte imbalances

Obsessive-compulsive personality

This personality disorder is common among eldest children. Here clients lack spontaneity, and they tend to be really serious, formal, disciplined and by-the-book. o Dependent personality o Obsessive-compulsive personality o Borderline personality o Narcissistic personality

"Our relationship is professional; therefore I will not see you socially."

• A client with a diagnosis of antisocial personality disorder is being discharged from the hospital. The client asks the nurse, "Can I have your phone number so that I can call you for a date?" What is the nurse's BEST response? o "We are not permitted to date clients." o "Our relationship is professional; therefore I will not see you socially." o "I'm glad you like me; however, I cannot give out my phone number." o "It is against my professional ethics to date clients."

Are generally necessary for the client to cope with a stressful situation

A nurse considers that, in a conversion (functional neurological symptom ) disorder, symptoms such as paralysis or blindness: o Are generally necessary for the client to cope with a stressful situation o Will usually resolve when the client learns to cope with ongoing family conflicts o Are conscious methods for getting attention o Will subside if the client is helped to focus on getting healthy

Underlying pathophysiology

What characteristic uniquely associated with psychophysiologic disorders differentiates them from somatic symptom disorders? o Emotional cause o Feeling of illness o Restriction of activities o Underlying pathophysiology

Gain 1 pound of weight a week

What is an appropriate goal for a client with anorexia nervosa? o Attend group therapy every day oGain 1 pound of weight a week o Talk about food for 1 hour a day o Eat every meal for a week

Bargaining

• A client diagnosed with lung cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse conclude the client is in? o Rationalization oDepression o Bargaining oFrustration

Mild

• A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client's learning abilities? o Panic o Moderate o Severe o Mild

"You sound upset; let's talk about it."

• An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse suggests the client come to dinner, the client refuses and states, "I don't want anyone to see me. Leave me alone." What is the nurse's best response? o "Only the staff members know why you are here." o "Certainly. I respect your wishes." o "It will be easier to face other people right away." o "You sound upset; let's talk about it."

Sexual masochism disorder

Sierra enjoys seeing the knees of Bobby and unconsciously has sexual fantasies of him whenever he wears shorts. This behavior is a characteristic of o Fetishism o Voyeurism o Exhibitionism o Frotteurism • This sexual dysfunction is defined as recurrent, intense sexually arousing fantasies, urges or behaviors involving the act of being humiliated, beaten, restrained or otherwise made to suffer. o Pedophilia o Sexual sadism disorder o Fetishistic disorder o Sexual masochism disorder

Risk for suicide

What is the most important observation a nurse makes with an adolescent diagnosed with an adjustment disorder? o Manic symptoms o Depressive symptoms o Anger and aggression o Risk for suicide

Explore ways to verbalize feelings

• A client is admitted and diagnosed with a conversion (functional neurological symptom) disorder. What is the primary nursing intervention? o Talk about the physical problems o Explore ways to verbalize feelings o Focus on the client's concerns regarding the symptoms o Explain how stress caused the physical symptoms

Apathy

• A client is diagnosed with conversion (functional neurological symptom) disorder. What is a typical characteristic of the client's reaction to the physical symptom o Apathy o Anxiety o Anger o Agitation

Recover the use of the affected leg but, under stress, develop similar symptoms again

• A client newly diagnosed with a conversion (functional neurological symptom) disorder is manifesting paralysis of a leg. The nurse can expect this client to: o Require continuous psychiatric treatment to maintain independent functioning o Demonstrate a spread of paralysis to other body parts o Follow an unpredictable emotional course in the future, depending on exposure to stress o Recover the use of the affected leg but, under stress, develop similar symptoms again

Meet emotional needs

• A nurse is caring for a client with the diagnosis of bulimia nervosa. The nurse understands that individuals with bulimia use food to: o Avoid growing up o Meet emotional needs o Control others o Gain attention

Weight gain of 6 pounds since admission 3 weeks ago

• Evaluation of clients diagnosed with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to become effective? o Weight gain of 6 pounds since admission 3 weeks ago o Statement that the hospitalization has been helpful o Remains in the dining room eating for 1 hour after others have left o Food is hidden in pockets of clothing

o Increased blood glucose level

• How should a nurse expect a client's anxiety to be manifested physiologically? o Increased blood glucose level o Constricted pupils o Decreased blood pressure o Narrowed bronchioles

Gender dysphoria

• In adults, this involves feelings of incongruence between one's assigned or biologic sex and one's gender identity. o Sexual dysphoria o Identity crisis o Gender dysphoria o Gender crisis

Encourage the parents to keep their child within the home environment

• The parents of an adolescent who is experiencing PTSD have decided to care for their child at home. What is the priority intervention that the home health nurse must include in the plan of care? o Help the parents identify their child's problems that cause them to be fearful o Encourage the parents to keep their child within the home environment o Discuss with the parents their feelings of ambivalence about what their child is enduring o Assist the parents to understand that their child may avoid emotional attachments

o Eye movement desensitization reprocessing

• This is an advanced practice intervention for PTSD where it processes traumatic memories through a specific eight-phase protocol that allows the person to think about the traumatic event while attending to other stimulation. o Eye movement desensitization reprocessing o Eye motor desensitization restructuring o Eye movement desensitization recording o Eye motor desensitization reprocessing

Based on realistic limits

• What characteristic of the environment is MOST therapeutic for clients with the diagnosis of bulimia nervosa? o Focused on food o Controlling o Empathic o Based on realistic limits

o Regressing to an earlier level of adjustment o Worrying about a variety of issues o Converting the anxiety into a physical symptom o Displacing the anxiety onto a less threatening object

• What clinical findings may be expected when a nurse assesses an individual diagnosed with an anxiety disorder? SELECT ALL THAT APPLY. o Acting with grandiose behavior o Regressing to an earlier level of adjustment o Worrying about a variety of issues o Converting the anxiety into a physical symptom o Displacing the anxiety onto a less threatening object

Avoid unpleasant events

• What is an appropriate way a nurse can help a client to decrease anxiety? o Avoid unpleasant events o Acquire skills with which to face stressful events o Prolong exposure to fearful situations o Introduce an element of pleasure into fearful situations

Help the client express concerns about body image

• Which nursing action is MOST important when providing counseling to an adolescent diagnosed with anorexia nervosa? o Avoid talking about food o Limit discussion of trivial topics o Identify the role the parents played in the development of the disorder o Help the client express concerns about body image

"You are concerned that this might happen again."

• A nurse speaks with a client who just experienced a panic attack. Which statement is MOST therapeutic when addressing the client's concerns? o "Episodes like this can be upsetting even though they do end." o "You are concerned that this might happen again." o "Your family must have thought you were having a heart attack." o "I would have been upset, too"

Bereavement may be of greater intensity and duration

• A parent whose daughter is killed in a school bus accident tearfully tells the nurse, "My daughter was just getting over the chickenpox and did not want to go to school, but I insisted that she go. My child's death is my fault." How should the nurse anticipate that perceiving a death as preventable will likely influence the grieving process? o Grieving process may progress to a psychiatric illness o Mourner may experience a pathologic grief reaction o Bereavement may be of greater intensity and duration o Loss may be easier to understand and accept.

Exhibits lack of empathy for others

• The nursing staff is discussing the BEST way to develop a relationship with a new client diagnosed with antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? o Possesses limited communication skills o Exhibits lack of empathy for others o Feels dependent on others o Engages in many rituals

"For now, allow the staff to handle her food needs."

• The parents of an adolescent female are upset about their daughter's diagnosis of anorexia nervosa and the treatment plan proposed. What is the best response by the nurse when the client's parents ask to bring food in for the client? o "For now, allow the staff to handle her food needs." o "Your concerns about food contribute to her problem." o "While in the hospital, she should eat the hospital food." o "It is important that you bring in what you think she'll eat."

o "You sound upset about not being able to have an erection."

• A 67-year-old man diagnosed with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? o "At your age, sex is not that important." o "Sex is not what it is implied to be." o "Maybe it is time that you speak to your health care provider about this." o "You sound upset about not being able to have an erection."

Industrialized societies

• A nurse considers the cultural factors that may influence the development of eating disorders. The nurse considers that eating disorders exist more frequently in: o Industrialized societies o Affluent families o European countries o Men rather than women

Schizotypal personality

• Observable in this personality disorder are magical thinking, ideas of reference, illusions and depersonalization. o Schizoid personality o Avoidant personality o Schizotypal personality o Antisocial personality

Becomes more self-aware

• A hospitalized client who was diagnosed with a borderline personality disorder consistently breaks the unit's rules. How will confronting the client about this behavior or discussing the behavior with the client help the client? o Controls anger o Becomes more self-aware o Reduces anxiety o Sets realistic goals

Perfectionist Engaging

• A nurse is working with a client who has the diagnosis of borderline personality disorder. What personality traits should the nurse expect the client to exhibit? SELECT ALL THAT APPLY o Manipulative o Perfectionist o Withdrawn o Engaging o Indecisive

"Let's discuss this concern a little more."

• During a routine yearly physical examination, an older adults says to a nurse, "I have not had sex lately because I can no longer get an erection!" What should be the nurse's initial response? o "There is medication available for erectile dysfunction." o "Be sure to tell your doctor about this problem." o "Let's discuss this concern a little more." o "This is an expected physiologic response to getting older."

"You are concerned about your sex life?"

• A client in whom sexual dysfunction is diagnosed comments to the nurse, "Well, I guess my sex life is over." What is the MOST appropriate response by the nurse? o "I'm sorry to hear that." o "You are concerned about your sex life?" o "Have you asked your health care provider about that?" o "Oh, you have a lot of good years left."

Factitious disorder

• A nurse identifies that a client is falsifying signs and symptoms of a medical disorder. What does this behavior usually indicate? o Factitious disorder o Out of contact with reality o Psychosis o Use of conversion defenses

3 tablets

• An adult reports anxiety, palpitations, and a feeling of impending doom. After a thorough physical examination, the health care provider diagnoses a panic attack. Lorazepam 1.5mg PO STAT is prescribed. Lorazepam is available in 0.5mg tablets. How many tablets should the nurse administer? o 3 tablets o 4 tablets o 2 tablets o Refer to prescribing physician.

Say "Excuse me" and leave the room

• Without knocking, a nurse enters the room of a young male client with the diagnosis of panic disorder and observes him masturbating. What should the nurse do? o Say "Excuse me" and leave the room. o Tactfully assess why he needs to masturbate. o In a calm, quiet manner say, "This behavior is inappropriate in the hospital." o Pretend nothing was seen and carry out whatever task needs to be done.

Lacking knowledge that anorexia can cause amenorrhea

• A 16-year-old high school student diagnosed with anorexia nervosa tells the school nurse that she thinks she is pregnant even though she had intercourse only once, over a year ago. What is the MOST appropriate inference for the nurse to make about the student? o Lacking knowledge that anorexia can cause amenorrhea o Lying about the last time she had intercourse o Using magical thinking o Submitting to peer pressure

Establish clear boundaries

• A client diagnosed with a borderline personality disorder. What is a realistic initial nursing intervention for this client's care? o Explore job possibilities with the nurse o Establish clear boundaries o Spend 1 hour twice a day discussing problems with the nurse Initiate discussion of feelings of being victimized

Dissociation

• A nurse if assessing a client for the use of defense mechanisms. Which defense mechanism separates certain mental processes from consciousness as though they belonged to another? o Conversion o Projection o Compensation oDissociation

Behavior

• A nurse is caring for a client diagnosed with a generalized anxiety disorder. Which factor should be assessed to determine the client's present status? o Responsiveness o Judgment o Behavior o Memory

Ask the client, "Have you ever acted on these thoughts?"

• An adult confides to a clinic nurse, "I have urges and fantasies to have sexual relations with children." What is the nurse's most appropriate response? o Inform the appropriate child protective services about the client and the thoughts the client has reported. o Explain that these thoughts are unacceptable and intense therapy is needed. o Ask the client, "Have you ever acted on these thoughts?" o Question the client, "Are you able to control your thoughts about sexual relations with children?"

Somatic symptom disorder

• An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical finding. What term best reflects what the client is experiencing? o Dissociation o Stress response o Anxiety reaction o Somatic symptom disorder

Helplessness o Denial o Confusion

• People involved in a bioterrorism attack often exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the immediate period after a traumatic event? SELECT ALL THAT APPLY o Altruism o Helplessness o Denial o Confusion o Guilt

o Illness anxiety disorder

A health care provider refers a 52-year-old male client to the mental health clinic. The history reveals that the man's wife died from colon cancer 6 months ago, and since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests prove negative. Recently, he has stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease? o Illness anxiety disorder o Somatic symptom disorder o Conversion disorder o Body dysmorphic disorder

Rewards positive behavior

• A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client's physical condition is stabilized, the health care provider, in conjunction with the client and parents, decides to institute a behavior modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy? o Deconditions fear of weight gain o Reduces anxiety-producing situations o Rewards positive behavior o Decreases unnecessary restrictions

Client's ability to change will be limited unless there is a readiness to accept the uncertainty associated with change

• A 22-year-old client with a diagnosis of antisocial personality disorder is being discharged and is to continue psychotherapy on an outpatient basis. When evaluating the chances for improvement, what outcome should the nurse anticipate? o Client will not change unless the parents are willing to set and keep firm limits o Client's prognosis for adjusting to a limited lifestyle is excellent o Client's ability to change will be limited unless there is a readiness to accept the uncertainty associated with change Client requires intensive psychotherapy along with an anxiolytic drug to produce a remission

o Open communication

• A child has been hospitalized repeatedly for illnesses with unknown etiologies. Finally, the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the nurse's most therapeutic approach with the patient involved? o Open communication o Confrontation o Validation of the child's physical status o Health teaching about the child rearing

Ask the child to describe the touching.

• A child tells the school nurse, "My father has been getting into bed with me at night and touching me." What should the nurse do next? o Report the child's conversation to child protective services. o Tell the teacher to report any inappropriate behavior o Ask the child to describe the touching. o Contact the father to come to the school immediately

o Tell the client it is frustrating not to get the correct tray, but throwing the tray at the dietician is unacceptable behavior

• A client diagnosed with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietician, I am going to throw this tray at her!" What is the nurse's MOST appropriate response? o Tell the client it is frustrating not to get the correct tray, but throwing the tray at the dietician is unacceptable behavior Inform the client that the behavior is inappropriate and send the client out of the dining room o Inform the client that throwing the tray at the dietician will make matters worse and may result in being placed in seclusion. o Suggest that the client calm down and explain that sometimes trays get mixed up

"Your comments will be kept confidential because I am your advocate."

• A client diagnosed with a personality disorder tells a nurse, "I want to tell you something, but you must promise to keep it a secret." Which comment by the nurse could lead to splitting among the staff? o "I cannot promise to keep what you say confidential from the rest of the staff." o "Your comments will be kept confidential because I am your advocate." o "Trust me to do what is in you best interests with the information, which includes discussing it with the team." o "I am part of a team that shares important information about clients."

Stay nearby without initiating conversation

• A client diagnosed with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? o Explain details of the care being given o Stay nearby without initiating conversation o Accept the client's crying o Encourage unrestricted family visits

"Develop a wide variety of coping strategies."

• A client diagnosed with generalized anxiety disorder says to the nurse, "What can I dot to prevent overreacting to stress? "What is the nurse's BEST response? "Improve your time management skills." o "Ignore situations that you cannot change." o "Hone your problem-solving skills." o "Develop a wide variety of coping strategies."

o "Would you like to leave the group for a while?"

• A client has a history of a conversion reaction that involves a weakness in the right arm that periodically progresses to paralysis. This client is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After assessing the client, what should the nurse ask? o "Would you like to leave the group for a while?" o "What emotion were you feeling before you felt the weakness?" o "Exactly when did the weakness begin?" o "Is this similar to what you usually experience?"

Extroverted and dramatic

• A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client? o Extroverted and dramatic o Boastful and egotistical o Aggressive and manipulative o Rigid and perfectionistic

Provide the client who was masturbating with periods of private time.

• A client is admitted to a long-term care facility and placed in a semiprivate room. After the second night on the unit the client's roommate reports that the client is masturbating at night and demands another room. What is the nurse's most appropriate initial intervention? o Inform the client who is masturbating that this behavior is inappropriate and should not continue. o Provide the client who was masturbating with periods of private time. o Move the roommate who made the report to another room. o Tell the roommate that this is acceptable behavior and the client has the right to engage in it.

Identifies when anxiety is developing

• A client is diagnosed with generalized anxiety disorder. For what behavior should the nurse assess a client to determine the effectiveness of therapy? o Takes medication as prescribed o Participates in activities o Identifies when anxiety is developing o Learns how to avoid anxiety

o Arrives early and waits quietly to be called for the tests

• A client is scheduled for several diagnostic studies. Which behavior BEST indicates to the nurse that the client has received adequate preparation? o Checks the appointment card repeatedly o Requests that the tests be reexplained o Arrives early and waits quietly to be called for the tests Paces up and down the hallway the morning of the tests

Be firm, consistent, and understanding

• A client with a diagnosis of borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client. SELECT ALL THAT APPLY o Be firm, consistent, and understanding o Provide an unstructured environment to promote self-expression o Record but ignore marked shifts in mod, suicidal threats, and temper displays because these last only a few hours. o Focus on specific behaviors o Use and authoritarian approach because this type of client needs to learn to conform to the rules of society

Focusing on daily activities but avoiding discussion of the eye discomfort

• A client with a history of stabbing pain in the eyes and blurring and gradual loss of vision is examined by an ophthalmologist, a neurologist, and an internist, all of whom find no organic cause. When eye complaints increase, the client is admitted to a mental health unit. After keeping the patient safe, what is the PRIORITY nursing intervention? o Exploring feelings about possible impending blindness o Encouraging involvement in group activities o Focusing on daily activities but avoiding discussion of the eye discomfort o Requesting a description of the eye discomfort

Discussion of plans for each of the possible outcomes of a trial

• A client with the diagnosis of antisocial personality disorder is openly discussing interpersonal difficulties with family members and the boss at work from whom money has been stolen. The client presently is facing criminal charges. Which behavior best indicates that the client is meeting treatment goals? o Expression of resignation about difficult spousal and children relationships o Discussion of the decision to file a grievance against the employer o Expression of feelings of resentment toward the employer o Discussion of plans for each of the possible outcomes of a trial

o Say, "Another staff member is coming in; I will leave and return later"

• A client's severe anxiety and panic are often considered to be "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing? o Remain quiet so that personal feelings of anxiety do not become apparent to the client o Say, "Another staff member is coming in; I will leave and return later" o Refocus the conversation on some pleasant topics o Say to the client, "Calm down; you are making me anxious, too"

Self-destructive behavior, Impulsiveness, Labile

• A college student is brought to the mental health clinic by the parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? SELECT ALL THAT APPLY. o Ritualistic behavior o Self-destructive behavior o Impulsiveness oPsychomotor retardation o Labile mood

Correct answers: Investigate own feelings about sexuality,Treat the client with respect.,Encourage the client to explore feelings,Accept the decision to have sex reassignment surgery.,Explore ways that the decision can be share with significant others.

• A male client with the diagnosis of gender dysphoria disorder has been dressing and functioning in society as a woman for 2 years and has decided to have sex reassignment surgery. He tells a nurse that all his life he has considered himself to be female. Place these nursing interventions in order of priority. Correct answers: Investigate own feelings about sexuality,Treat the client with respect.,Encourage the client to explore feelings,Accept the decision to have sex reassignment surgery.,Explore ways that the decision can be share with significant others.

Tell the client that the behavior is unacceptable and to stop

• A male client with the diagnosis of pedophilia is admitted to the psychiatric hospital because of repeated episodes of exhibitionism. In the recreation room the client exposes himself to a nurse and begins to masturbate. How should the nurse respond? o Tell the client that the behavior is unacceptable and to stop. o Remove the client from the recreation room and escort him to his own room. o Recognize that the behavior is part of his illness and obtain a prescription for a libido-lowering medication. o Turn away from the client and ignore the behavior.

o Reduction of anxiety through control over food

• A nurse admits an adolescent to the psychiatric unit with the diagnosis of anorexia nervosa. What is the PRIMARY gain a client with anorexia achieves from this disorder? o Release from school responsibilities because of illness o Separation from parents secondary to hospitalization o Reduction of anxiety through control over food o Increased parental attentiveness related to massive weight loss

Respect the client's need for social isolation

• A nurse begins a relationship with a client diagnosed with the diagnosis of schizotypal personality disorder. What is the BEST initial nursing response? o Respect the client's need for social isolation o Set limits on manipulative behavior o Encourage participation in group therapy o Recognize that seductive behavior is expected

Avoiding focusing on the client's physical symptoms

• A nurse if caring for a client who has a diagnosis of conversion (functional neurological symptom) disorder with paralysis of the lower extremities. Which is the most therapeutic nursing intervention? o Avoiding focusing on the client's physical symptoms o Explaining to the client that there is nothing wrong o Helping the client follow through with the physical therapy plan o Encouraging the client to try to walk

Lack of control over binge eating episodes

• A nurse if caring for a client who was admitted recently to the psychiatric unit with the diagnosis of bulimia nervosa. Which clinical assessment must be present to meet the diagnostic criteria for bulimia nervosa? o Binge-eating episodes that occur at least once a week o Body weight less than 85% of that expected o Amenorrhea in postmenarchal females o Lack of control over binge eating episodes

The co-worker may need help with grieving

• A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" of if the mother's name is mentioned. What does the nurse conclude about this behavior? o The co-worker was extremely attached to the mother o It is an expected response o The co-worker may need help with grieving o Most people cry when their mother dies

Redirect the conversation with the nurse to physical symptoms

• A nurse is caring for a client diagnosed with a somatic symptom disorder. What should the nurse anticipate that this client will do? o Write down conversations to assist in remembering information o Redirect the conversation with the nurse to physical symptoms o Monopolized conversations about the anxiety being experienced o Start a conversation asking the nurse to recommend palliative care

Usually is unable to postpone gratification

• A nurse is caring for a client diagnosed with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care? o Suffers from extreme anxiety o Has a great sense of responsibility toward others o Rapidly learns by experience if punished o Usually is unable to postpone gratification

Fatigue o Secondary amenorrhea

• A nurse is caring for an underweight adolescent girl who is diagnosed with anorexia nervosa. What are common characteristic of girls with this disorder that the nurse should identify when obtaining a health history and performing a physical assessment? SELECT ALL THAT APPLY. o Tachycardia o Pyrexia o Fatigue o Secondary amenorrheao Heat intolerance

Systematic desensitization using relaxation techniques

• A nurse is interviewing a client diagnosed with a phobia. Which treatment should the nurse inform the client has the highest success rate? o Systematic desensitization using relaxation techniques o Psychotherapy aimed at rearranging psychotic thought processes o Psychoanalytic exploration of repressed conflicts of an earlier developmental phase o Insight therapy to determine the origin of the fear

Tell the interrupting client, "I'll be back to talk with you after I orient this new client."

• A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse's attention in manipulative and uses acting-out behaviors when demands are unmet. How should the nurse intervene? o Introduce the two clients and suggest that the client join them on a tour of the facility o Leave the new client, saying, "I'll talk with the other client until things calm down" o Suggest that the client requesting attention speak with another staff member o Tell the interrupting client, "I'll be back to talk with you after I orient this new client."

Setting mutual goals for the relationship

• A nurse is working in the orientation phase of a therapeutic relationship with a client diagnosed with borderline personality disorder. What will be MOST difficult for the client at this stage of the relationship? o Terminating the session on time o Controlling anxiety o Setting mutual goals for the relationship o Accepting the psychiatric diagnosis

Has behaviors and an appearance that appear appropriate

• A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? o Is obese and attempting to lose weight o Has a distorted body image and sees the body as fat o Has behaviors and an appearance that appear appropriate oIs struggling with a conflict between dependence and independence

An unconscious means of reducing stress

• A nurse plans care for a client diagnosed with a conversion (functional neurological symptoms) disorder based on the understanding that it is: o An intentional attempt to gain attention o A conscious defense against anxiety o A physiologic response to stress o An unconscious means of reducing stress

Identifies the feelings underlying the acting-out behavio

• An adolescent client with a diagnosis of antisocial personality disorder was admitted to the hospital because of substance use disorder and repeated sexual acting-out behavior. Which client behavior best supports the nurse's evaluation that actions directed toward modifying the behavior of this client are successful? o Identifies the feelings underlying the acting-out behavior o Discusses the need to seduce other adolescents o Recognizes the need to conform to society's norms o Promises never to take drugs again

Arrives on time for meals without being told

• An adolescent diagnosed with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior is effective? o Contacts the family frequently by telephone between meals o Arrives on time for meals without being told o Organizes an aerobic exercise group for other clients o Begins to clip recipes from magazines

Attempt to establish a trusting relationship with the adolescent

• An adolescent is admitted to the psychiatric service with the diagnosis of anorexia nervosa. The adolescent has lost 20 pounds in 6 weeks and is very thin but is excessively concerned about being overweight. What is the MOST important initial nursing intervention? o Compliment the physical appearance of the adolescent o Explain the value of adequate nutrition to the adolescent o Attempt to establish a trusting relationship with the adolescent o Explore the reasons why the adolescent does not want to eat

"What are you using for birth control and protection from sexually transmitted infection?"

• An adult client confides to the nurse that she enjoys engaging in sex with multiple male adult sex partners simultaneously. What is the nurse's most appropriate response? o "These men are abusing you, and you should go to the police to report them." o "What are you using for birth control and protection from sexually transmitted infection?" o "I recommend that you seek counseling for this problem." o "Don't you think that having sex with multiple sex partners is immoral?"

• 1 - Sociocultural attitudes exert pressure for people to attain an idealized body o 2 - Dieting in an attempt to maintain control o 3 - Self-esteem increases as weight is lost o 4 - Secondary gains reinforce the anorectic client's behaviors o 5 - Progressive deterioration in physical status

• Anorexia nervosa follows a cyclic pattern. List the following statements in order of progression through this cycle. The top most would be the first step and bottom is the fifth step. o 1 - Sociocultural attitudes exert pressure for people to attain an idealized body o 2 - Dieting in an attempt to maintain control o 3 - Self-esteem increases as weight is lost o 4 - Secondary gains reinforce the anorectic client's behaviors o 5 - Progressive deterioration in physical status

search it

• Relatives of the victims of a home invasion attack in which several family members were killed received crisis intervention services. Which therapy is MOST beneficial after the immediate event has passed? o Grief o Psychoeducational o Psychoanalytic o Family

Inform the client in a matter-of-fact tone that everyone must remain with the group

• The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the MOST appropriate response by the nurse? o Instruct the client with a loud voice to get in the bus so the group can go home o Tell the client that the baseball player will not be permitted to give anyone an autograph o Inform the client in a matter-of-fact tone that everyone must remain with the group o Hold the client by the arm to prevent leaving the group

Desire to improve her self-image Ritualistic behaviors

• The nurse interviews a young female client diagnosed with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? SELECT ALL THAT APPLY oDesire to improve her self-image o Ritualistic behaviors o Low achievement in school and little concern for grades o Satisfaction with and a desire to maintain her present weight o Supportive family relationship

Set limits

• What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa? o Set limits o Demonstrate empathy o Focus on dietary nutrition o Maintain control

o "It doesn't get hard during sex anymore."

• What statement during a yearly physical examination indicates to a nurse that a male client may have a sexual arousal disorder? o "I have no interest in sex." o "I climax almost before we even get started." o "It takes forever before I finally have an orgasm." o "It doesn't get hard during sex anymore."

Is attempting to divide the staff, and the behavior should be reported to the other staff members

• When talking with one of the day nurses, a client with the diagnosis of anorexia nervosa states that the day nurses give better care and are nicer than the night nurses. The client also asks a question that the day nurse is aware was already answered by one of the night nurses. What conclusion should the nurse make about the client? o Is attempting to divide the staff, and the behavior should be reported to the other staff members o Has negative feelings about the night nurses, and the nurses should be informed of these feelings o Needs assistance in exploring and verbalizing feelings about the night nurses o Is trying to develop a bond of trust with a staff member, which should be supported

Lacks self-confidence

• Which description is not consistent with clients having histrionic personality disorder? o Lacks self-confidence o Attention-seeker o Seductive o Self-dramatizing

Other covert or overt emotional problems

• Which is a frequent finding in clients with paraphilic disorders? o Over association with society's fringe groups o Gonadal and pituitary hormone deficiencies o Other covert or overt emotional problems o Inadequate development of the sexual organs

Provide clear boundaries and consequences

• Which nursing intervention is MOST important for a client who has the diagnosis of antisocial personality disorder? o Present an empathetic and democratic approach o Use a gentle and reassuring approach o Teach and role-model assertiveness o Provide clear boundaries and consequences