420 Practice Q's for Exam 3

A patient diagnosed with an eating disorder has a nursing diagnosis of low self-esteem. Which nursing intervention would address this problem? A. Offer independent decision-making opportunities. B. Review previously successful coping strategies. C. Provide a quiet environment with decreased stimulation. D. Allow the patient to remain in a dependent role.

A. Offer independent decision-making opportunities.

A patient with a long history of BN is seen in the ED. The patient having visual hallucinations, is restless, and has dry mucous membranes. Which is most likely the cause of this patient's symptoms? A. Mood disorders. B. Nutritional deficits. C. Vomiting. D. Binge eating.

B. Nutritional deficits.

A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client's plan of care? A. Allow the client to select preferred meal times. B. Establish consequences for purging behavior. C. Provide the client with a high-fat diet at the start of treatment. D. Implement one-to-one observation during meal times.

D. Implement one-to-one observation during meal times.

Which of the following client statements would indicate the need for additional teaching about benzodiazepines? a. "I can't drink alcohol while taking diazepam" b. "I can stop taking the drug whenever I want" c. "Valium can make me drowsy, so I shouldn't drive for a while" d. "Valium will help my tight muscles feel better"

b. "I can stop taking the drug whenever I want"

A client who is pacing and wringing his hands states, "I just need to walk" when questioned by the nurse about what he is feeling. Which of the following responses by the nurse would be most therapeutic? a. "you just need to sit down and relax" b. "are you feeling anxious" c. "is something bothering you" d. "You must be experiencing a problem now"

b. "are you feeling anxious"

A nurse is caring for a client who smokes and has lung CA. The client reports "I am 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

b. Denial

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? SATA a. Chronic pain b. Depressed immune system c. Increased BP d. Panic attacks e. Unhappiness

b. Depressed immune system c. Increased BP e. Unhappiness Panic attacks indicates a prolonged or maladaptive stress response

A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? SATA a. Hypothermia b. Hallucinations c. Muscular flaccidity d. Diaphoreses e. Agitation

b. Hallucinations d. Diaphoreses e. Agitation

A nurse working in an emergency department is caring for a client who has a benzodiazepine toxicity due to overdose. Which of the following actions is the nurse's priority? a. Administer the flumazenil b. Identify the clients level of orientation c. Infuse IVF d. Prepare the client for gastric lavage

b. Identify the clients level of orientation initial assessment, before giving flumazenil

A nurse is providing preop teaching to a client who was just informed that she needs emergent surgery. The client has a RR of 30, 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

b. Moderate

A client says that she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but Im not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? a. Learn to practice mindfulness b. Use assertiveness techniques c. Exercise regularly d. Rely on the support of a close friend

b. Use assertiveness techniques

A client with acute stress disorder has avoided feelings of anger toward her rapist and is unable to verbally express them. The nurse suggests which of the following activities to help her express her feelings? a. Working on a puzzle b. Writing in a journal c. Meditating d. Listening to music

b. Writing in a journal

The parents of a newly diagnosed 15 y/o with anorexia nervosa are meeting with the nurse during the admission process. Which of the following remarks by the parents would the nurse interpret as typical for a client with anorexia nervosa? a. "We've given her everything and look how she repays us" b. "She's had behavior problems for the past year both at home and at school" c. "She's been a model child. We've never had any problems with her" d. "We have 5 children, all normal kids with some problems at times"

c. "She's been a model child. We've never had any problems with her"

When developing a plan of care for a client with acute stress disorder who lost her sister in a boating accident, which of the following would the nurse expect to initiate? a. Helping the client to evaluate her sisters behavior b. Telling the client to avoid the details of the accident c. Facilitating progressive review of the accident and its consequences d. Postponing discussion of the accident until the client brings it up

c. Facilitating progressive review of the accident and its consequences helps client integrate feelings and memories and to begin the grieving process

The client with OCD is taking clomipramine (Anafranil) for his disorder. The nurse would expect the client to exhibit side effects similar to those of which of the following medications? a. Fluoxetine (Prozac) b. Sertraline (Zoloft) c. Imipramine (Tofranil) d. Fluvoxamine

c. Imipramine (Tofranil)

After being discharged from the hospital with acute stress disorder, a client is referred to the outpatient clinic for follow-up. Which of the following is most important for the client to use for continued alleviation of anxiety? a. Recognizing when she is feeling anxious. b. Understanding reasons for her anxiety. c. Using adaptive and palliative methods to reduce anxiety. d. Describing the situations preceding her feelings of anxiety.

c. Using adaptive and palliative methods to reduce anxiety.

A nurse observes a client who has OCD repeatedly applying, removing, and reapplying make-up. 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. adverse effect of antidepressant medication

c. attempt to reduce anxiety

A client with PTSD needs to find new housing and wants to wait for a mont before setting another appointment to see the nurse. The nurse interprets this action as which of the following? a. A method of avoidance b. A detriment to progress c. The end of treatment d. A necessary occurrence

d. A necessary occurrence a "time-out" is common and necessary for the client to focus on emergent problems and solution... not necessarily the other answers, finding housing may be stressful and require a lot of energy and concentration with none left for emotional stress of treatment

A client often jumps when spoken to and complains of feeling uneasy. She says "It's as though something bad is going to happen." Which of the following actions would be most beneficial to the client? a. Leaving her alone b. Demonstrating technical competency c. Conveying optimistic verbalizations d. Reducing environmental stimulation

d. Reducing environmental stimulation

When discussing eating disorders with a group of adolescents, the nurse incorporates information that persons living within the culture of the US often experience difficulty with weight control because they unconsciously equate food with which of the following? a. Love and affection b. Power and control c. Status and prestige d. Survival and growth

a. Love and affection parties and celebration and families center usually include food, when upset you offer food, often a source of comfort

A woman with anorexia nervosa weighs 98 pounds; she is 5' 6". She tells you," My hips are too large, I need to lose another 5 or 6 pounds. This represents: a. Magnification b. Rationalization c. Catastrophizing d. Projective identification

a. Magnification

A client diagnosed with bulimia tells the nurse that she eats excessively when she is upset and then vomits so she won't gain a lot of weight. Which of the following nursing diagnostic categories would be the most appropriate for the client? a. Disabled family coping b. Ineffective coping c. Imbalanced nutrition: more than body requirements d. Anxiety

b. Ineffective coping

Which of the following points would the nurse include when teaching a client about panic disorder? a. Staying in the house will eliminate panic attacks b. Medication should be taken when symptoms start c. Symptoms of a panic attack are time limited and will abate d. Maintaining self-control will decrease symptoms of panic

c. Symptoms of a panic attack are time limited and will abate helps to decrease fear about what is occurring; not d, because it could be the brain/biochemicals so client may not have control over it

The client with agoraphobia refuses to walk down the hall to the group room. Which of the following responses by the nurse would be most appropriate? a. "I know you can do it" b. "Try holding onto the wall as you walk" c. "You can miss group one time" d. "I'll walk with you"

d. "I'll walk with you" activates adaptive coping for client with high anxiety and decreased motivation/energy other options maintains the client's avoidance

When assessing a client with anorexia nervosa, the nurse would expect to find which of the following? a. hyperthermia, oliguria, and bradycardia b. lanugo, hypothermia, and hypotension c. constipation, dysmenorrhea, and hypertension d. diarrhea, dry skin, and menorrhagia

b. lanugo, hypothermia, and hypotension

While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid? a. Chocolate. b. Cheese. c. Alcohol. d. Shellfish.

c. Alcohol

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 behaviors c. Distract the client with a TV show d. Stay with the client and remain quiet

d. Stay with the client and remain quiet

A patient is leaving a residential treatment facility after one month of treatment for AN. Which outcome is appropriate during discharge planning for this patient? A. Patient will perform NG tube feeding independently. B. Patient will verbalize recognition of "fat" body misperception. C. Patient will discuss importance of monitoring weight daily.

B. Patient will verbalize recognition of "fat" body misperception.

It is said, "Eating disorders are never about food." Identify the dynamic most often associated with the development of eating disorders: ________________________

Controlling Stressors

A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam (Valium) for generalized anxiety disorder. Which of the following is appropriate for the nurse to include in the teaching? A. 3 to 6 weeks of treatment is required to achieve therapeutic benefit. B. Combining alcohol with diazepam will produce a paradoxical response. C. Diazepam has a lower risk for dependency than other antianxiety medications. D. Report confusion as a potential indication of toxicity.

D. Report confusion as a potential indication of toxicity.

A nurse is teaching a client about stress reduction techniques. Which of the following statements indicates the client understands? a. "Cognitive reframing will help me change my irrational thoughts to something positive" b. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate" c. "Biofeedback causes my body to release endorphins so that I feel less stress and less anxiety" d. "Mindfulness allows me to prioritize stressors that I have in my life so that I have less anxiety"

a. "Cognitive reframing will help me change my irrational thoughts to something positive"

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lbs. 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"

a. "Life isn't worth living if I gain weight"

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statement actions should the nurse make? a. "Tell me how you're feeling right now" b. "You should focus on the positive things in your life to decrease 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"

a. "Tell me how you're feeling right now"

A client with obsessive-compulsive disorder (OCD) arrives late for an appointment with the nurse at the outpatient clinic. During the interview he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which of the following statements by the nurse would best deal with the client's feelings of "going crazy"? a. "What do you mean when you say you think you're going crazy?" b. "Most people feel that way occasionally" c. "I don't know enough about you to judge" d. "You sound perfectly sane to me"

a. "What do you mean when you say you think you're going crazy?" open-ended question allows for nurse to have insight on the meaning of his words and actions

A nurse is preparing to obtain 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? SATA a. "What is your relationship like with your 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"

a. "What is your relationship like with your family?" c. "Would you describe your current eating habits?" e. "Can you discuss your feelings about your appearance" not b -> Why Q not d -> promotes cognitive distortion, implies current appearance is not acceptable

The client, a veteran of the Vietnam war who has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which of the following responses by the nurse is appropriate? a. "You did what you had to do at that time." b. "Maybe you didn't kill as many people as you think." c. "How many people did you kill?" d. "War is a terrible thing."

a. "You did what you had to do at that time." evaluating past behavior in the context of the trauma, the patient is evaluation past behavior in present context and feels guilty *I feel like this is a good q*

Which of the following statements by a client who has been taking buspirone (Buspar) as prescribed for 2 days indicates the need for further teaching? a. "this medication will help my tight, aching muscles" b. "I may not feel better for 7-10 days" c. "The drug does not cause physical dependence" d. "I can take the medication with food"

a. "this medication will help my tight, aching muscles" not effective for somatic symptoms like tension, good for cognitive symptoms like worry and apprehension

The nurse would teach a client with an anxiety disorder who is taking a benzodiazepine about using which of the following in combination with his medication? a. Antacids b. Acetaminophen c. Vitamins d. Aspirin

a. Antacids impairs the absorption of benzodiazepines

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. Assessing the client's risk for self-harm b. Instilling hope for positive outcomes c. Encourage the client to participate in group therapy sessions d. Encouraging the client to participate in treatment sessions

a. Assessing the client's risk for self-harm

A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night, which causes pain in his moth. The nurse should identify which of the following interventions as possible measures to manage the clients bruxism? SATA a. Concurrent administration of buspirone b. Administration of a different SSRI c. Use of a mouthguard d. Changing to a different class of anti anxiety medication e. Increasing the dose of paroxetine

a. Concurrent administration of buspirone c. Use of a mouthguard d. Changing to a different class of anti anxiety medication concurrent use/additional SSRI will worsen bruxism

A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse include in the discussion? a. Excessive stressors cause the client to experience distress b. The body's initial adaptive response to stress is denial c. Absence of stressors results in homeostasis d. Negative rather than positive stressors produce a biological response

a. Excessive stressors cause the client to experience distress

A nurse is assessing a client who has GAD. Which of the following findings would the nurse expect? SATA a. Excessive worry for 6 months b. Impulsive decision making c. Delayed reflexes d. Restlessness e. Need for reassurance

a. Excessive worry for 6 months d. Restlessness e. Need for reassurance

A client with panic disorder is taking alprazolam (Xanax) 1 mg P.O. three times daily. The nurse understands that this medication is effective in blocking the symptoms of panic because of its specific action on which of the following neurotransmitters? a. Gamma-amino butyrate b. Serotonin c. Dopamine d. Norepinephrine

a. Gamma-amino butyrate aka GABA

A client is brought to the hospital ED by his brother. The client is perspiring profusely, breathing rapidly, and c/o dizziness and palpitations. Problems of a CV nature are ruled out, and the client's dx is tentatively listed as a panic attack. After the symptoms pass, the client states, "I thought I was going to die." Which of the following responses by the nurse would best? a. It was very frightening for you. b. We would not have let you die. c. I would have felt the same way d. But you are ok now

a. It was very frightening for you.

A client with OCD reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I cant stop until I do it just right." The nurse interprets the client's behavior as most likely representing an effort to obtain which of the following? a. Relief of anxiety b. Control of his thoughts c. Attention from others d. Safe expression of hostility

a. Relief of anxiety

The nurse is talking with a 16 y/o weighing 76 pounds and diagnosed with anorexia without purging behaviors about developing a mutually acceptable behavior contract. Which of the following are crucial components to be negotiated with the client? SATA a. Selection of a nutritionally balanced menu b. Definition of the amount and type of daily physical activity c. Expectation of eating 75-100% of each meal d. Issues to be addressed besides food and weight e. Privileges to be used as rewards for weight gain

a. Selection of a nutritionally balanced menu b. Definition of the amount and type of daily physical activity d. Issues to be addressed besides food and weight e. Privileges to be used as rewards for weight gain Behavioral contracts typically focus on increasing the client's responsibility for selecting balanced meals, limiting excessive exercise, focusing on issues such as self-esteem, sense of control, and emotions, and rewards for weight gain Not C, expecting the client to initially eat more than 25% of each meal would be overwhelming to the client

When developing a teaching plan for a high school health class about anorexia nervosa, which of the following would the nurse include as the primary group affected by this disease? a. Women, age at onset between 12-20 y/o b. men onset during college c. Women, onset typically after 30 y/o d. men, onset before 20 y/o

a. Women, age at onset between 12-20 y/o

The nurse is assessing a person with AN. Which frequently co-occurring disorder should the nurse assess for? a. Substance abuse b. Depressive disorders c. Anxiety disorders d. Personality disorders

b. Depressive disorders

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? SATA a. Reassure the client that everything will be ok b. Discuss prior use of coping mechanisms with the client c. Ignore the client's anxiety so that she will not be embarrassed d. Demonstrate a calm manner while using simple and clear directions e. Gather information from the client using close-ended questions

b. Discuss prior use of coping mechanisms with the client d. Demonstrate a calm manner while using simple and clear directions

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? SATA a. Amenorrhea b. Hypokalemia c. Mottling of the skin d. Slightly elevated body weight e. Presence of lanugo on the face

b. Hypokalemia d. Slightly elevated body weight a, c, e are with anorexia

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use initially? a. Explain the effects of stress on the mind and body. b. Reassure the client that her feelings are typical reactions to serious trauma. c. Reassure the client that her symptoms are temporary. d. Acknowledge the unfairness of the client's situation.

b. Reassure the client that her feelings are typical reactions to serious trauma. people respond normally to abnormal situations! option a may be helpful later

A client with OCD, who was admitted yesterday morning, must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed having breakfast yesterday with the other clients. Which of the following actions would the nurse institute to help the client be on time for breakfast? a. Tell the client to make his bed one time only b. Wake the client an hour earlier to perform his ritual c. Insist that the client stop his activity when it's time for breakfast d. Advise the client to have breakfast first before making his bed

b. Wake the client an hour earlier to perform his ritual so he can be on time for breakfast with others, allow the time for rituals because he needs to keep his anxiety in check Can't take ritual away because panic will ensue, nurse will work slowly to put limits on rituals

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following responses should the nurse make? a. "Many clients are concerned about their weight. However, the dietician 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, lets talk about your recent accomplishments" d. "You are not overweight, and the staff will ensure that you do not gain weight while your are in the hospital. When know that is important"

c. "I understand you have concerns about your weight, but first, lets talk about your recent accomplishments"

A client newly diagnosed with bulimia is attending the nurse-led group at the mental health center. She tells the group that she came only because her husband said he would divorce her if she didn't get help. Which of the following responses by the nurse would be the most appropriate? a. "You sound angry with your husband. Is that correct?" b. "You will find that you like coming to group. These people are a lot of fun" c. "Tell me more about why you are here and how you feel about that" d. "Tell me something about what has caused you to be bulimic"

c. "Tell me more about why you are here and how you feel about that" May reveal more info about why she came, what led to her diagnosis not a: puts the focus on the husband and the focus should be her not d: requires the client to have insight on the cause of the disease which she may not currently have, and it may be too early in the relationship

A client with agoraphobia without panic disorder asks the nurse to advise her on which type of treatment would be best for her illness. Which of the following would be true for the nurse to suggest? a. Insight therapy b. Group therapy c. Behavior therapy d. Psychoanalysis

c. Behavior therapy systemic desensitization, flooding, exposure, and self-exposure are most effective for clients with phobias

The nurse notices that a client with OCD must get up and move to another area when someone sits next to her. Which of the following actions by the nurse would be most therapeutic? a. ignoring the client's behavior b. questioning the client about her ritual c. Conveying awareness of the need for the ritual d. Telling the other clients to follow the client when she moves

c. Conveying awareness of the need for the ritual

A nurse is caring for a client who is to begin taking fluoxetine for treatment of GAD. Which of the following statements indicates the client understands the use of this medication? a. I will take the medication at bedtime b. I will follow a low-sodium diet on this med c. I will need to discontinue this medication slowly d. I will be at risk for weight loss with long-term use of this medication

c. I will need to discontinue this medication slowly

Persons with Bulimia Nervosa are: a. Underweight b. Overweight c. Near or normal weight

c. Near or normal weight

Select the neurotransmitter dysregulation most often associated with eating disorders. a. GABA b. Dopamine c. Serotonin d. Acetylcholine

c. Serotonin closely followed by dopamine

Identify the emotion most often experienced by a person following an episode of binge eating. a. Anger b. Euphoria c. Shame d. Relief

c. Shame

The client with a fear of eating in public places or in front of other people has finished eating lunch in the dining area in the nurse's presence. Which of the following statements by the nurse would reinforce the client's positive action? a. "It wasn't so hard now was it?" b. "At supper, I hope to see you eat with a group of people" c. "You must have been hungry" d. "It is a sign of progress to eat in the dining area"

d. "It is a sign of progress to eat in the dining area"

During the initial interview, a client with compulsive eating disorder remarks "I cant stand myself and the way I look." Which of the following statements by the nurse would be most therapeutic? a. "Everyone who has the same problem feels like you do" b. "I don't think you look bad at all" c. "Don't worry, you'll soon be back in shape" d. "Tell me more about your feelings"

d. "Tell me more about your feelings"

A client with acute stress disorder states to the nurse "I keep having horrible nightmares about the car accident that killed my daughter. I shouldn't have taken her with me to the store." Which of the following responses by the nurse would be most therapeutic? a. "Don't keep torturing yourself with horrible thoughts" b. "Stop blaming yourself. It's only hurting you" c. "Let's talk about something that is a bit more pleasant" d. "The accident just happened and could not have been predicted"

d. "The accident just happened and could not have been predicted" objective observation instead of the patient's perception, reduces feelings of blame and guilt

A nurse is caring for a client who states "I am so stressed at work because of my coworker. He expected me to finish his work because he's too lazy!" When discussing effective communication, Which of the following statements by the client to his coworker indicates client understanding? a. "You really should complete your own work. I don't think its right to expect me to complete your responsibilities" b. "Why do you expect me to finish your work? You must realize I have my own responsibilities" c. "It isn't fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor" d. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities"

d. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities"

Which of the following nursing diagnoses would the nurse formulate as the priority for a client who is admitted to the mental health unit with a diagnosis of anorexia nervosa and who is 5'4" tall and weighs only 82 lbs? a. Low self esteem r/t feelings of inadequacy and loss of control b. Disturbed body image r/t self-view of being overweight c. Interrupted family processes r/t over-protectiveness and avoidance of conflict d. Imbalanced nutrition less than body requirements r/t severe restriction of intake

d. Imbalanced nutrition less than body requirements r/t severe restriction of intake state of starvation, in danger of dying or suffering same to body; all are important, but priority for starving and need for referring

When teaching a group of adolescents about anorexia nervosa, the nurse would describe this disorder as being characterized by which of the following? a. excessive fear of becoming obese, near-normal weight, and self-critical body image b. obsession with the weight of others, chronic dieting, and altered body image c. Extreme concern about dieting, calorie-counting, and an unrealistic body image d. Intense fear of becoming obese, emaciation, and a disturbed body image

d. Intense fear of becoming obese, emaciation, and a disturbed body image