Exam Two

Which of the following would the nurse expect to see directly after a rape? Select all that apply. A. Expressed response pattern B. Delayed rape reaction C. Controlled response pattern D. Silent rape reaction E. Compound rape reaction

A & C

Which of the following would the nurse include on the care plan for a patient in regard to Risk for self-directed violence? Select all that apply A. The nurse will assess for substance use B. The patient will not harm self C. The nurse will assess for level of anxiety D. The patient will be able to recognize signs of increasing anxiety E. The patient will not argue with the nurse

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Which situation would the RN identify as placing a client at high risk for caregiver abuse? A. Antonia, an adult child, quits her job to move in and care for a patient with severe dementia. B. Mr. Wright, an elderly man with severe heart disease, resides in a personal care home and is frequently visited by his adult child C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives help from several adult children D. Antolnette cares for her husband who is in early stages of Alzheimer's disease and has a network of available support persons

Ans: A Rational: In this situation, the adult child has given up her usual role as well as moved to her place of residence to care for her parent. Caring for someone with severe dementia is very successful, requiring 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse.

a 20-year-old college student has been brought to the psychiatric hospital by her parents. Her admitting diagnosis is borderline personality disorder. When talking with her parents, which information would the nurse expect to be included in the client's history? Select all that apply. A. Impulsiveness B. Lability of mood C. Ritualistic behavior D. Psychomotor retardation E. Self-destructive behavior

Ans: A, B, C

Patients with dependent personality disorder exhibit which of the following symptoms? Select all that apply A. Lack of self-confidence B. Passive C. Fear of separation D. Socially anxious E. Afraid of rejection

A, B, & C

Which of the following are neurobiological changes that the nurse would observe in someone who has binge-eating disorder? Select all that apply A. Decreased secretion of cholecystokinin B. Alteration in serotonin and norepinephrine C. Increased levels of endogenous opioids D. Delayed gastric emptying E. Enlarged stomach capacity

Ans: A, D, E

Jane has been diagnosed with bulimia nervosa. Which symptoms would you expect Jane to present with? Select all that apply. A. Feels disgusted and guilty after binging episode B. Intense fear of gaining weight or becoming fat C. Body shape and weight influence self-evaluation D. Induces vomiting and takes laxatives to avoid gaining weight E. Recurrent episodes of binge eating in a short period of time with loss of control

Ans: C, D, E

The nurse is assessing a patient who present as very organized, disciplined, and efficient, but is also inflexible and perfectionistic. Which diagnosis best fits the description of this patient? A. Avoidant B. Dependent C. Narcissistic D. Obsessive-compulsive

D.

The nurse is assessing a newly admitted patient for depression. Which predisposing factors would be important to include in the assessment? Select all that apply A. Genetics B. Neuroendocrine disorders C. Electrolyte disturbances D. Hormonal disturbances E. Nutritional disturbances

A, B, C, D, E

The nurse is discussing ECT with a client who asks how long it will be before she feels better. The nurse explains that the beneficial effects of ECT usually occur within: A. One week B. Three weeks C. Four weeks D. Six weeks

Ans: A Rational: Beneficial effects of ECT usually are evident after the first several treatments. Since treatments are administered at intervals of 48 hours, these effects are apparent after one week of therapy. Beneficial effects of ECT therapy are usually seen before three weeks.

Which of the following physical symptoms would you expect to see with bulimia nervosa? Select all that apply A. Electrolyte imbalance B. Gastric tears C. Dehydration D. Peripheral edema E. Hyperthermia

Ans: A, B, C

A nurse working in an inpatient psychiatric setting is most likely to encounter which of the following personality disorders? Select all that apply. A. Dependent B. Antisocial C. Avoidant D. Borderline E. Histrionic

B, D, E

Which of the following symptoms would the nurse expect to find in a patient with bipolar 1 disorder, most recent episode manic. Select all that apply. A. Decreased appetite B. Decreased need for sleep C. Impairment in functioning D. Irritability E. Distractibility

B, D, E

During group Debbie takes over to talk about her problems regarding the boyfriend who just broke up with her and then begins to flirt with the men in the session and asks them about how pretty she looks today. Which diagnosis is most consistent with Debbie's presentation of symptoms? A. Antisocial B. Borderline C. Histrionic D. Narcissistic

C.

A patient is in the recovery room after an emergency surgery. The nurse is assessing the patient and observes a flat affect, some bizarre behaviors with odd beliefs, suspiciousness, and tangential speech. What diagnosis would be most appropriate for this patient? A. Antisocial B. Paranoid C. Schizoid D. Schizotypal

D.

Which of the following are examples of sexual violence? Select all that apply A. Marital rape B. Statutory rape C. Acquaintance rape D. Incest E. Sexual exploitation of a child

A, B, C, D, E

Which of the following would the nurse expect to find when assessing a patient for abuse? Select all that apply. A. Patient seems frightened B. Patient exhibits extremes in behavior C. Patient has been abusing family pets D. Patient exhibits signs of depression E. Patient has delays in emotional development

A, B, C, D, E

Bipolar disorder can also be medication induced. Which of the following medications would be important to assess for in a patient who presents with acute mania? Select all that apply. A. Steroids B. Anticoagulants C. Anxiolytics D. Oral contraceptives E. Anticonvulsants

A, C, D, E

Lithium is used to treat bipolar disorder. Which side effects would you expect to see in a patient with lithium toxicity? Select all that apply. A. Tremors B. Skin rash C. Nausea and vomiting D. Bruising E. Blurred vision

A, C, E

Which of the following tests are routinely employed in the initial diagnosis of depression? Select all that apply A. Thyroid function B. Liver function c. Kidney function D. Vitamin B and folate levels E. Electrolyte panel

A, D, E

Which of the following patients would meet criteria for a bipolar disorder? Select all that apply A. Lauren has a long history of depression, but is complaining of irritability, her thoughts being all over the place, not being able to focus, has started a lot of home projects, and spending a lot of time online lately B. Stacey was admitted with labile mood and irritability, rapid speech, inability to focus attention, and impairment in functioning. C. Kelly presents with a history of depression and elevated mood, getting fired from her job, and delusions of grandeur. D. Brandon presents with euphoria and increased sexual inhibition and a history of depression E. Jeremy complains of history of depression, but now presents with decreased need for sleep, irritability, distractibility, flight of ideas, and pressured speech

A, E

A client with borderline personality disorder is admitted to the unit after slashing his wrist. Which of the following goals is most important after promoting safety? A. Establish a therapeutic relationship with the client B. Identify whether splitting is present in the client's thoughts C. Talk about the client's acting out and self-destructive tendencies D. Encourage the client to understand why he blames others

Ans: A Rational: After promoting safety, the nurse establishes a rapport with the client to facilitate appropriate expression of feelings. At this time, the client isn't ready to address the unhealthy behavior. A therapeutic relationship must be established before the nurse can effectively work with the client on self-destructive tendencies and the issues of splitting.

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A. "You look upset. Would you like to talk about it?" B. "I'd like to know more about your family. Tell me about them." C. "I understand that you lost your partner. I don't think I could go on if that happened to me." D. "You look very sad. How long have you been this way?"

Ans: A Rational: Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific.

The RN is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? A. Flexible role functioning between parents B. History of the parent having been abused as a child C. Single-parent home situation D. Presence of parental mental illness

Ans: B Rationale: Not A = parents who are flexible in their roles are characteristic of healthy functioning, not abuse not C = not an established risk factor for child abuse by a parent not D = not an established risk factor for child abuse by a parent

The RAISE approach stands for Recovery After an Initial Schizophrenia Episode. What are the approaches used in RAISE? A. Cognitive remediation B. Vocational support C. Personalized treatment plan D. Case management E. Family education and support

Ans: B, C, D, E

Which of the following patients would be diagnosed with schizophrenia according to the diagnosis criteria? Select all that apply. A. Jared avolition, apathy, and lack of abstract thinking B. Jimmy has delusions of persecution and suicidal ideation C. Justin has auditory and visual hallucinations and flat affect D. Jenny has neologisms and echopraxia E. Jeremy has auditory hallucinations and delusions of reference

Ans: C, D, E

A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit's rules. This behavior should be confronted because it will help the client: A. Control anger B. Reduce anxiety C. Set realistic goals D. Become more self-aware

Ans: D Rational: Clients must first become aware of their behavior before they can change it. Occurs after the client is aware of the behavior and has a desire to change the behavior.

Sharon presents with a depressed mood, low self-esteem, decreased energy, and poor concentration, which she tells the nurse she feels like she's "had my whole life." However, over the last few years, it is starting to affect her family life. Which DSM diagnosis would Sharon be diagnosed with? A. Major Depressive Disorder B. Persistent depressive disorder C. Premenstrual dysphoric disorder D. Disruptive mood dysregulation disorder

B.

Traci presented to the clinic as a victim of sexual assault. The nurse is developing a care plan that empowers Traci to have control over decisions about her treatment. What type of approach is the nurse using? A. Cognitive behavioral therapy B. Crisis intervention C. Family therapy D. Trauma-informed care

B.

Aidan has been diagnosed with disruptive mood dysregulation disorder. Which of the following symptoms would the nurse expect to find during assessment? Select all that apply A. Suicidal Ideation B. Depressed mood C. Temper outburst D. Issues at school E. Irritable mood

C, D, and E

When working with the nurse during the orientation phase of the relationship, a client with a borderline personality disorder would probably have the most difficulty in: A. Controlling anxiety B. Terminating the session on time C. Accepting the psychiatric diagnosis D. Setting mutual goals for the relationship

Ans: D Rational: Clients with borderline personality disorders frequently demonstrate a pattern of unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals.

Which of the following would the nurse expect to see in a child who is being neglected? Select all that apply A. Patient exhibits extremes in behavior B. Patient appears malnourished and states he is hungry C. Patient has been abusing family pets D. Patient is dressed in shorts and tank top in the middle of a cold winter E. Patient appears dirty and disheveled

B, D, E

Jan has not responded to any of the antidepressants that she has been prescribed and the provider wants to try a noninvasive procedure that uses electrical waves to stimulate areas in the cerebral cortex. Which procedure best describes what the provider wants to do? A. Vagal nerve stimulation B. Deep brain stimulation C. Electroconvulsive therapy D. Repetitive transcranial magnetic stimulation

D

A patient approaches a nurse with a look of distress and anguish on his face and shares, "Can't you hear him? It's the devil. He's telling me I'm going to hell." What symptom of schizophrenia is this patient experiencing? A. Delusions of reference B. Circumstantiality C. Hallucinations D. Grandiose delusions

Ans: C

Which of the following patients with schizophrenia is at the highest risk for injury to self or others? A. Has little to no family support B. Has a family history of mood disorders C. Has command hallucinations D. Has delusions of reference

Ans: C

During a well-child checkup, a mother tells the RN about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face. The RN analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except: A. Conflictual relationship of parents B. Inconsistent communication patterns C. Rigid, authoritarian roles D. Use of violence to establish control

Ans: A Rational: In the question there was no evidence that the parents were in conflict. Often in dysfunctional families, one child is singled out to be the victim and is the recipient of blame for the problems.

A group of nursing students is currently learning about family violence. Which of the following is true about the top mentioned? A. Family violence affects every socioeconomic level B. Family violence is caused by drugs and alcohol abuse C. Family violence predominantly occurs in lower socioeconomic levels. D. Family violence rarely occurs during pregnancy

Ans: A Rational: Not B = although violence is associated with substance abuse, it is not the singular cause Not C = false statement Not D = False, about 23% of all pregnant women seeking prenatal care are victims of abuse

During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"

Ans: A Rational: The use of simple, direct question, asked in an empathetic manner, is best to validate the presence of an abusive situation B, C, D = the other questions are indirect and may not lead to the discussion of an abusive situation

Which physical symptoms would you expect to see in your patient diagnosed with anorexia nervosa? Select all that apply. A. Amenorrhea B. Hypotension C. Tooth erosion D. Bradycardia E. Lanugo

Ans: A, B, D, E

Which of the following symptoms would indicate that a patient has binge-eating disorder? Select all that apply A. Eating very quickly and until uncomfortably full. B. Compensatory mechanisms are used to prevent weight gain C. Recurrent episodes of binge-eating where the person has no control D. Eating alone because of embarrassment about the amount of food E. Fear of gaining weight or getting fat

Ans: A, C, D

Schizophrenia has four phrases. Which of the following accurately depicts a particular phase? Select all that apply. A. The patient has significant deterioration with depressive symptoms B. That patient is experiencing visual hallucinations and no other symptoms C. The patient's positive symptoms are improved, but the negative symptoms may linger D. The patient is experiencing grandiose delusions and anosognosia E. The patient has signs that are hard to recognize, but include withdrawal, lack of peer relationships, and poor school performance.

Ans: A, C, D, E

Sheila tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. A. Help Sheila to develop a plan to ensure safety, including phone numbers for emergency help. B. Help Sheila to get her boyfriend into an appropriate treatment program. C. Communicate acceptance, avoiding any implication that Sheila is at fault for not leaving. D. Help Sheila to explore available options, including shelters and legal protection. E. Tell Sheila that she should leave because things will not improve F. Reinforce concern for Sheila's safety and her right to be free of abuse

Ans: A, C, D, F Rational: These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client's feeling responsible for the abuse. Advising the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.

The RN is working in the emergency department. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? A. Contact the appropriate legal services B. Ensure privacy for interviewing the victim away from the abuser C. Establish a rapport with the victim and the abuser D. Request the presence of a security guard

Ans: B Rational: Privacy away from the abuser, is important. This allows the victim to discuss the problem freely without fear of reprisal from the abuser (especially if she decides to return to the abusive situation). Not A = in this situation, it is not the nurse's responsibility to make the decision to report the abuse. However, whenever the injury is inflicted with a gun, knife, or other weapons, the nurse is obligated to report the abuse Not C = although the nurse would want to establish rapport with the victim, her initial concern would be to establish rapport with the abuser Not D = the situation does not describe the abuser as currently violent or under the influence of substances; therefore requesting a security presence is inappropriate at this time.

During a home visit to a family of three: a mother, father, and their child. The mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse? A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening B. The nurse commends the mother's effort and agrees to let her handle things C. The nurse commends the mother's efforts and also contacts protective services D. The nurse confronts the mother's failure to protect the child

Ans: C Rational: A and B are inappropriate; the nurse is failing to provide for the child's safety and is not following legal guidelines Not D = the nurse is alienating the mother, as well as failing to follow legal guidelines and ensure the child's safety.

Which of the following statement is typical for a client diagnosed with a paranoid personality disorder? A. "I understand you're the one to blame." B. "I must be seen first; it's not negotiable." C. "I see nothing humorous in this situation." D. "I wish someone would select the outfit for me."

Ans: C Rational: Clients with paranoid personality disorder tend to be extremely serious and lack a sense of humor.

Which of the following interventions is important for a client with paranoid personality disorder taking olanzapine (Zyprexa)? A. Explain the effects of serotonin syndrome B. Teach the client to watch for extrapyramidal adverse reactions C. Explain that the drug is less effective if the client smokes

Ans: C Rational: Olanzapine (Zyprexa) is less effective for clients who smoke cigarettes. Olanzapine doesn't cause euphoria and extrapyramidal side effects aren't a problem. However, the client should be aware of adverse effects such as tardive dyskinesia.

A nursing student is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is: A. Assess the scope of the abuse problem B. Analyze family dynamics C. Implement measures to ensure the victim's safety D. Teach appropriate coping skills

Ans: C Rational: The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety Not A and B = the question is asking about implementing a specific nursing action, not assessing the problem or analyzing the family dynamics Not D = teaching coping skills is important; however, the priority action involves ensuring safety.

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down and talk. The client requesting the nurse's attention is extremely manipulative and uses socially acting-out behavior when demands are unmet. The nurse should: A. Suggest that the client requesting attention speak with another staff member B. Leave the new client and talk with the other client to avoid precipitating acting out behavior C. Tell the interrupting client to sit down and be patient, stating, "I'll be back as soon as possible." D. Introduce the two clients and suggest that the client join the new client and the nurse on the tour.

Ans: C Rational: This sets realistic limits on behavior without rejecting the client

Mr. Peterson, 35, is admitted for bipolar illness, manic phase, after assaulting his landlord in an argument over Mr. Peterson is staying up all night playing loud music. Mr. Peterson is hyperactive, intrusive, and has rapid, pressured speech. He has not slept in three days and appears thin and disheveled. Which of the following is the most essential nursing action at this time? A. Providing a meal and beverage for Mr. Peterson to eat in the dining room. B. Providing linens and toiletries for Mr. Peterson to attend to his hygiene. C. Consulting with the psychiatrist to order a hypnotic to promote sleep D. Providing for client safety by limiting his privileges.

Ans: C Rational: Mr. Peterson has been assaultive with the landlord, and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgement and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety A = food and fluids are necessary. However, Mr. Peterson's hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run" will provide needed nourishment B = when hyperactivity decreases, then approach Mr. Peterson's regarding hygiene and grooming needs C = medications will be ordered. However, a thorough evaluation must be done first

A 34-year-old woman is admitted for treatment of depression. Which of these symptoms would the nurse be least likely to find in the initial assessment? A. Inability to make decisions B. Feelings of hopelessness C. Family history of depression D. Increased interest in sex

Ans: D Rational: Interest in sex is markedly decreased in depression A = indecisiveness and fear of being wrong are common in depression B = depression creates feelings that nothing will ever improve C = the risk of depression is increased when there is a family history

Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? A. Contact the child's parents and ask about the child's injury B. Encourage the child to be truthful with her C. Question the teacher about the parent's behavior D. Report suspicion of abuse to the proper authorities.

Ans: D Rational: The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a midemeanor violation on the part of the nurse Not A = the parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency Not B = although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate. Not C = questioning the teacher may or may not provide validation of the nurse's suspicions; regardless this intervention does not ensure the child's safety, which is the priority

The RN is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? A. The child is fearful of the caregiver and other adults B. The child has a lack of peer relationships C. The child has self-injurious behavior D. The child has an interest in things of a sexual nature

Ans: D Rational: An 8-year old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is the priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show an unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.