MENTAL HEALTH BOOK QUESTIONS EXAM 3

14. A client who experienced a myocardial infarction was transferred from critical care to a step-down unit. The client then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the client's needs. When the nurse manager intervenes directly with this client, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that you are not satisfied with the care you are receiving." c. "Let's talk about why you use your call light so frequently. It is a problem." d. "You frustrate the staff by calling them so often. Why are you doing that?"

ANS: A This client is experiencing anxiety associated with a serious medical condition. Verbalization is an effective outlet for anxiety. "I'm wondering if you are anxious ..." focuses on the emotions underlying the behavior rather than the behavior itself. This opening conveys the nurse's willingness to listen to the client's feelings and an understanding of the commonly seen concern about not having a nurse always nearby as in the intensive care unit. The other options focus on the behavior or its impact on nursing and do not help the client with her emotional needs. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

16. The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder? a. attention deficit hyperactivity disorder (ADHD). b. posttraumatic stress disorder (PTSD). c. communication disorder. d. an anxiety disorder.

ANS: A Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

12. Which comment by a client who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. "My employer should have paid for a health club membership for me." b. "My family will see me through this. It won't be easy, but I will never be alone." c. "My heart attack was no fun, but it showed me up the importance of a good diet and more exercise." d. "I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily."

ANS: A Blaming someone else and rationalizing one's failure to exercise are not adaptive coping strategies. Seeing the glass as half full, using social and religious supports, and confronting one's situation are seen as more effective strategies. The distracters demonstrate effective coping associated with a serious medical condition. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. A child diagnosed with attention deficit hyperactivity disorder (ADHD) will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? a. CNS stimulants b. Tricyclic antidepressants c. Antipsychotics d. Anxiolytics

ANS: A CNS stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

1. Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty maintaining relationships b. Chronic low self-esteem related to excessive negative feedback c. Deficient fluid volume related to abnormal eating habits d. Anxiety related to nightmares and repetitive activities

ANS: A Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

15. Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child has been raised by a parent with recurring major depressive disorder. b. The child's best friend was absent from the child's birthday party. c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.

ANS: A Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk-enhancing. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

13. A nurse assesses a client diagnosed with conversion (functional neurological) disorder. Which comment is most characteristic of this client? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

ANS: A Clients with conversion (functional neurological) disorder demonstrate a lack of concern regarding the seriousness of symptoms. This lack of concern is termed la belle indifférence. There is also a specific, identifiable cause for the development of the symptoms; in this instance, the death of a parent would precipitate stress. The distracters relate to sexual dysfunction and illness anxiety disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

4. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a. Family therapy b. Bibliotherapy c. Play therapy d. Art therapy

ANS: A Family therapy focuses on problematic family relationships and interactions. The patient has identified problems within the family. Play therapy is more appropriate for younger patients. Art therapy and bibliotherapy would not focus specifically on the identified problem. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

13. Parents of an adolescent diagnosed with a conduct disorder (CD) say, "We don't know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?" Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy

ANS: A In PCIT, the therapist sits behind one-way mirrors and coaches parents through an ear audio device while they interact with their children. The therapist can suggest strategies that reinforce positive behavior in the adolescent. The goal is to improve parenting strategies and thereby reduce problematic behavior. Behavior modification therapy may help the adolescent, but the parents are seeking help for themselves. MST is much broader and does not target the parents' need. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

15. An adolescent diagnosed with conduct disorder (CD) has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication? a. Second-generation antipsychotic b. Antianxiety medication c. Calcium channel blocker d. b-blocker

ANS: A Medications for CD are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms. Second-generation antipsychotics are likely to be prescribed. b-blocking medications may help to calm individuals with intermittent explosive disorder by slowing the heart rate and reducing blood pressure. Calcium channel blockers reduce blood pressure but are not used for persons with impulse control problems. An antianxiety medication will not assist with impulse control. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

24. A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child demonstrating what? a. resiliency. b. a passive temperament. c. at risk for post-traumatic stress disorder (PTSD). d. intellectualization to deal with problems.

ANS: A Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"

ANS: A Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The client's dependency needs may be evident through losses of abilities. When secondary gains are prominent, the client is more resistant to giving up the symptom. There may be a history of abuse or doctor shopping, but the question does not assess the associated gains. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is the soldier describing? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: A Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.

ANS: A The adolescent and the parents must agree on a behavioral contract that clearly outlines rules, expected behaviors, and consequences for misbehavior. It must also include rewards for following the rules. The adolescent will continue to experience anger and frustration. The adolescent and parents must continue with family therapy to work on boundary and communication issues. It is not necessary to separate the adolescent from the family to work on these issues. Separation is detrimental to the healing process. While it is helpful for the adolescent to identify peers who are a positive influence, it is more important for behavior to be managed for an adolescent diagnosed with a CD. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

8. Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

ANS: A The client in a dissociative fugue state relocates and lacks recall of his life before the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from one's body or from the external reality is an indication of depersonalization disorder. Losing track of several minutes when highly anxious is not an indication of a dissociative disorder and is common in states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants without any explanation for these is suggestive of dissociative identity disorder, particularly when periods are "lost" to the client (blackouts). PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

23. Which assessment made by a client best supports dissociative fugue? a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

ANS: A The client in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." What is the nurse's best intervention? a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

ANS: A The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

24. After major reconstructive surgery, a client's wounds dehisced. Extensive wound care was required for 6 months, causing the client to miss work and social activities. Which physiological response would be expected for this client? a. Vital signs return to normal. b. Release of endogenous opioids would cease. c. Pulse and blood pressure readings are elevated. d. Psychomotor abilities of the right brain become limited.

ANS: A The scenario presents chronic and potentially debilitating stress. The helpless and out of control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses initially result in rapid heart rate and respiration. After many hours, days, or months the body cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous system. This parasympathetic response results in the heart rate and respiration slowing down and a decrease in blood pressure. Individuals with dissociative disorders have altered communication between higher and lower brain structures due to the massive release of endogenous opioids at the time of severe threat. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

11. Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Social isolation b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity

ANS: A This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

2. Which assessment findings suggest the possibility of a factitious disorder, imposed on self-type? (Select all that apply.) a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries c. Going from one doctor to another seeking the desired response d. Claims illness to obtain financial benefit or other incentive e. Difficulty describing symptoms

ANS: A, B Persons with factitious disorders, imposed on self-type, typically have a history of multiple hospitalizations and medical workups, with negative findings from workups. Sometimes they have even had multiple surgeries seeking the origin of the physical complaints. If they do not receive the desired response from a hospitalization, they may elope or accuse staff of incompetence. Such persons usually seek treatment through a consistent health care provider rather than doctor shopping, are not motivated by financial gain or other external incentives, and present symptoms in a very detailed, plausible manner indicating considerable understanding of the disorder or presentation they are mimicking. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? (Select all that apply.) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. maximizing opportunities for exercise and play.

ANS: A, B, C, E, F The child's symptoms and behavior suggest that he is exhibiting PTSD. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. The nurse interviewing a client with suspected post-traumatic stress disorder (PTSD) should be alert to which client findings? (Select all that apply.) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

ANS: A, B, C, E, F These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors are expected in obsessive-compulsive disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Post-traumatic stress disorder (PTSD) e. Reactive attachment disorder f. Disinhibited social engagement disorder

ANS: A, B, D Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this client's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

4. A nurse assesses a client suspected of having somatic symptom disorder. Which assessment findings regarding this client support the suspected diagnosis? (Select all that apply.) a. Female b. Reports frequent syncope c. Rates pain as "1" on a scale of "10" d. First diagnosed with a skin rash at age 12 e. Reports insomnia often resulting from back pain

ANS: A, B, D, E Common symptoms for primary care visits are chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, paralysis, unexplained skin rashes and numbness. This disorder is more common in women than in men. Clients with conversion disorder would have a tendency to underrate pain. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

4. Which assessment findings present familial risks for a child to develop a psychiatric disorder? (Select all that apply.) a. Having a mother diagnosed with schizophrenia b. Being the oldest child in a family c. Living with an alcoholic parent d. Being an only child e. Living in an urban community

ANS: A, C Familial risk factors that correlate with child psychiatric disorders include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. Having a parent with a substance abuse problem increases the risk of marital discord. A family history of schizophrenia presents a genetic risk. Being in a middle-income family, living in an urban community, and being an only or oldest child do not represent adversity. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. A nurse's neighbor says, "I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?" The nurse should respond by noting that what serious medical conditions may be complicated by emotional stress? (Select all that apply.) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

ANS: A, C, D, E A number of diseases can be worsened or brought to awareness by intense emotional stress. Immune disorders can be complicated associated with detrimental effects of stress on the immune system. Others can be brought about indirectly, such as cardiovascular disease due to acute or chronic hypertension. Hip fractures are not in this group. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. A client diagnosed with a somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this client? (Select all that apply.) a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

ANS: A, E The client's verbalization is consistent with spiritual distress. The client's description of being unable to provide for and burdening the family indicates ineffective role performance. No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional conflict. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

3. After the sudden death of his wife, a man says, "I can't live without her ... she was my whole life." What is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

ANS: B Adjustment disorders may be associated with grief. A statement that validates a bereaved person's loss is more helpful than false reassurances and clichés. It signifies understanding. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. A medical-surgical nurse works with a client diagnosed with a somatic symptom disorder. An understanding how what client characteristic will facilitate care planning? a. readily seek psychiatric counseling. b. be resistant to accepting psychiatric help. c. attend psychotherapy sessions without encouragement. d. be eager to discover the true reasons for physical symptoms.

ANS: B Clients diagnosed with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these clients reject both. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

1. Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a. Voluntary control of symptoms b. Client's style of presentation c. Results of diagnostic testing d. The role of secondary gains

ANS: B Clients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the clients with conversion (functional neurological) disorder often exhibit less concern with the symptom they are presenting than would be expected. Neither disorder involves voluntary control of the symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological basis would be found for the symptoms). Secondary gains can occur in both disorders but are not necessary to either. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

15. A client reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results were normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? a. Conversion (functional neurological) disorder b. Illness anxiety disorder (hypochondriasis) c. Somatic symptom disorder d. Factitious disorder

ANS: B Clients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

11. The unlicensed assistive personnel (UAP) says to the nurse, "That client with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" What is the nurse's best reply? a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

ANS: B Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in clients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the client should only gradually be given information about her past. Asking questions that require recall that the client does not possess will only add frustration. Quiet, undemanding activities should be provided as the client tolerates them and should be balanced with rest periods; the client's time should not be loaded with demanding or stimulating activities. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? a. Planned ignoring b. Establish firm limits c. Neutrally permit refusals d. Coaxing to gain compliance

ANS: B Firm limits are necessary to ensure physical safety and emotional security. Limit setting will also protect other patients from the teen's thoughtless or aggressive behavior. Permitting refusals to participate in the treatment plan, ignoring, coaxing, and bargaining are strategies that do not help the patient learn to abide by rules or structure. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

17. A soldier returned home from active duty in a combat zone and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

ANS: B Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

12. A client diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the client's behavior. b. Engage the client in a physical activity such as exercise. c. Isolate the client until the sensation has diminished. d. Administer a prn dose of antianxiety medication.

ANS: B Helping the client apply a grounding technique, such as exercise, assists the client to interrupt the dissociative process. Medication can help reduce anxiety but does not directly interrupt the dissociative process. Isolation would allow the sensation to overpower the client. It is not necessary to notify the health care provider. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

11. A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support which diagnosis? a. Conduct disorder (CD). b. Oppositional defiant disorder (ODD). c. Intermittent explosive disorder. d. Attention-deficit/hyperactivity disorder (ADHD).

ANS: B ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. Loading a virus is a vindictive behavior in retribution for a poor grade. Persons with CD are aggressive against people and animals; destroy property; are deceitful; violate rules; and have impaired social, academic, or occupational functioning. There is no evidence of explosiveness or distractibility. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A nurse works with a client diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the client learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

ANS: B Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the client understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the client to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase client distress. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. A client experiences blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this client? a. The client is suppressing accurate feelings regarding the problem. b. The client's anxiety is relieved through the physical symptom. c. The client's optic nerve transmission has been impaired. d. The client will not disclose genuine fears.

ANS: B Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that clients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously). PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

18. A client says, "I know I have a brain tumor despite the results of the magnetic resonance imaging (MRI). The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? a. "You do not have a brain tumor. The more you talk about it, the more it reinforces your belief." b. "Let's see if there are any other possible explanations for your vomiting." c. "You seem so worried. Let's talk about how you're feeling." d. "We need to talk about something else."

ANS: B Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. An 11-year-old diagnosed with oppositional defiant disorder (ODD) becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse's initial action to defuse the situation? a. Say to the child, "Tell me how you're feeling right now." b. Take the child swimming at the facility's pool. c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.

ANS: B Redirecting the expression of feelings into nondestructive, age-appropriate behaviors such as a physical activity helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to measures that are more restrictive. A shouting child will not likely engage in a discussion about feelings. A behavioral contract could be considered later, but first the situation must be defused. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

17. A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action? a. Give notice to the chief administrator at the school regarding the events. b. Encourage the victimized child to share feelings about the experience. c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.

ANS: B The behaviors by the bullying child create emotional pain and present the risk for physical pain. Encouraging the victimized child to share feelings about the experience provides the nurse an opportunity to further assess the situation as well as provide support to the child. The nurse should validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

5. A client is experiencing blindness related to conversion (functional neurological) disorder. To help the client eat, the nurse should implement which intervention? a. establish a "buddy" system with other clients who can feed the client at each meal. b. expect the client to feed self after explaining arrangement of the food on the tray. c. direct the client to locate items on the tray independently and feed self. d. address needs of other clients in the dining room, then feed this client.

ANS: B The client is expected to maintain some level of independence by feeding self, while the nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little support. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. A client experiencing blindness related to conversion (functional neurological) disorder states, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

ANS: B The client mentions that the symptoms make people more interested. This indicates that the client feels uninteresting and unpopular without the symptoms, thus supporting the nursing diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses are not present in the scenario. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

11. A client with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to client's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to client. What is an appropriate outcome for this client? a. Will assume roles and functions of other family members. b. Will demonstrate performance of former roles and tasks. c. Will focus energy on problems occurring in the family. d. Will rely on family members to meet personal needs.

ANS: B The client with a somatic symptom disorder has typically adopted a sick role in the family, characterized by dependence. Increasing independence and resumption of former roles are necessary to change this pattern. The distracters are inappropriate outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

19. Which comment by the parents of young children best demonstrates support of development of resilience and effective stress management? a. "Our children will be stronger if they make their own decisions." b. "We spend daily family time talking about experiences and feelings." c. "We use three different babysitters. All of them have college degrees." d. "Our parenting strategies are different from those our own parents used."

ANS: B The correct response demonstrates consistent nurturing, which is a vital component of building resilience in children. The incorrect responses are not necessarily unhealthy parenting behaviors, but they do not clearly demonstrate parental nurturing. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

ANS: B The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

14. The gas pedal on a person's car became stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this experience, afterward, which assessment finding would the nurse expect? a. Weight gain b. Flashbacks c. Headache d. Diuresis

ANS: B The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or "mind flight" may occur for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the distracters may or may not occur. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. Which prescription medication would the nurse expect to be prescribed for a client diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat co-morbid depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

ANS: B Various types of antidepressants may be helpful in somatic disorders not only directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood but also fatigue, pain perception, GI distress, and other somatic symptoms. Clients may benefit from short-term use of antianxiety medication (benzodiazepines) but require careful monitoring because of risks of dependence. Conventional antipsychotic medications would not be used, although selected atypical antipsychotics may be useful. Narcotic analgesics are not indicated. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

3. At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? (Select all that apply.) a. Report the finding to the official child protection social services agency. b. Educate all members of the family about potential safety risks in online environments. c. Talk with the parents about parental controls on the children's communication devices. d. Encourage the family to schedule daily time together without communication devices. e. Obtain the family's network password and examine online sites family members have visited.

ANS: B, C, D The nurse's focus is safety, including online environments. Education and awareness-based approaches are indicated to reduce the risks of potentially harmful behavior, including risks associated with cyberbullying. Parental controls on the children's devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family's network password and an invasion of privacy to inspect sites family members have visited. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

1. A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder imposed on another is suspected. Which nursing interventions are appropriate? (Select all that apply.) a. Increase private visiting time for the parents to improve bonding. b. Keep careful, detailed records of visitation and untoward events. c. Place mittens on the child to reduce access to ports and incisions. d. Encourage family members to visit in groups of two or three. e. Interact with the client frequently during visiting hours.

ANS: B, D, E Factitious disorder imposed on another is a condition wherein a person intentionally causes or perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with fecal material). When this disorder is suspected, the child's life could be at risk. Depending on the evidence supporting this suspicion, interventions could range from minimizing unsupervised visitation to blocking visitation altogether. Frequently checking on the child during visitation and minimizing unobserved access to the child (by encouraging small group visits) reduces the opportunity to take harmful action and increases the collection of data that can help determine whether this disorder is at the root of the child's illness. Detailed tracking of visitation and untoward events helps identify any patterns there might be between select visitors and the course of the child's illness. Increasing private visitation provides more opportunity for harm. Educating visitors about aseptic techniques would not be of help if the infections are intentional and preventing inadvertent contamination by the child himself would not affect factitious disorder by proxy. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

1. A nurse prepares to lead a discussion at a community health center regarding children's health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? (Select all that apply.) a. Autism b. Bullying c. Mental retardation d. Autism spectrum disorder e. Intellectual development disorder

ANS: B, D, E Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It is important for the nurse to use current terminology. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what? a. integration of self-concept. b. inpatient treatment for the child. c. loneliness and increase self-esteem. d. language and communication skills.

ANS: C Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

8. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits? a. "Attention everyone: we are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

ANS: C Setting limits uses clear, sharp statements about prohibited behavior and guidance for performing a behavior that is expected. The incorrect options represent a threat, use of restructuring (which would be inappropriate in this instance), and a direct appeal to the child's developing self-control that may be ineffective. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

6. A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy b. Simple restitution c. Social skills group d. Insight-oriented group therapy

ANS: C Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

16. An adolescent was recently diagnosed with oppositional defiant disorder (ODD). The parents say to the nurse, "Isn't there some medication that will help with this problem?" What is the nurse's best response? a. "There are no medications to treat this problem. This diagnosis is behavioral in nature." b. "It's a common misconception that there is a medication available to treat every health problem." c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d. "There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you."

ANS: C The parents are seeking a quick solution. Medications are generally not indicated for ODD. Comorbid conditions that increase defiant symptoms, such as ADHD, should be managed with medication, but no comorbid problem is identified in the question. The nurse should give information on helpful strategies to manage the adolescent's behavior. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Information will focus on which medication likely to be prescribed? a. Paroxetine b. Imipramine c. Methylphenidate d. Carbamazepine

ANS: C Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

15. A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with post-traumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.

ANS: C Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

21. A client diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The client says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as at what degree of success? a. marginally b. minimally c. partially d. totally

ANS: C Decreased preoccupation with symptoms and increased ability to perform activities of daily living suggest partial success of the treatment plan. Total success is rare because of client resistance. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

10. A client states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

ANS: C Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD (Acute Stress Disorder) experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the client experiences only one symptom. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, "I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family." Which nursing diagnosis is most applicable? a. Chronic low self-esteem related to role within the family b. Decisional conflict related to compliance with school requirements c. Defensive coping related to adjustment to changes in family relationships d. Disturbed personal identity related to self-perceptions of changing family dynamics

ANS: C Depression is often associated with impulse control disorder. The correct nursing diagnosis refers to the patient's dysfunctional management of feelings associated with upcoming changes to the family. The teen displays self-imposed isolation. The distracters are not supported by data in the scenario. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

20. When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses what strategy? a. guided imagery. b. talk focused on a specific issue. c. play and talk about a play activity. d. group discussion about selected topics.

ANS: C Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

ANS: C Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

21. A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)? a. Re-experiencing b. Hyperarousal c. Avoidance d. Psychosis

ANS: C Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. A client diagnosed with a somatic symptom disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." What is the mos important nursing assessment? a. mood. b. cognitive style. c. secondary gains. d. identity and memory.

ANS: C Secondary gains should be assessed. The client's dependency needs may be met through care from the family. When secondary gains are prominent, the client is more resistant to giving up the symptom. The scenario does not allude to a problem of mood. Cognitive style and identity and memory assessment are of lesser concern because the client's diagnosis has been established. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

7. To assist clients diagnosed with somatic symptom disorders, which nursing interventions have the highest priority? a. explain the pathophysiology of symptoms. b. help these clients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d. investigate each physical symptom as it is reported.

ANS: C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the client as a person rather than as a condition. The need to gain attention with the use of symptoms is reduced over the long term. A desired outcome would be that the client would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the client reports them. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

19. Which treatment modality should a nurse recommend to help a client diagnosed with a somatic symptom disorder to cope more effectively? a. Flooding b. Response prevention c. Relaxation techniques d. Systematic desensitization

ANS: C Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the client's perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

4. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The client had ambivalent feelings about her husband.

ANS: C Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

ANS: C The autonomic nervous system is comprised of the sympathetic (fight or flight response) and parasympathetic nervous system (relaxation response). In times of stress, the sympathetic nervous system is stimulated. A person would experience stress associated with the experience of being in danger. The peripheral nervous system responds to messages from the sympathetic nervous system. The limbic system processes emotional responses but is not specifically part of the autonomic nervous system. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. An 11-year-old diagnosed with oppositional defiant disorder (ODD) becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a. Ignore the child's behavior. b. Send the child to time-out for 2 hours. c. Take the child to the gym and engage in an activity. d. Role-play a more appropriate behavior with the child.

ANS: C The child's behavior warrants an active response. Redirecting the expression of feelings into nondestructive age-appropriate behaviors, such as a physical activity, helps defuse the situation here and now. This response helps the child learn how to modulate the expression of feelings and exert self-control. This is the least restrictive alternative and should be tried before resorting to a more restrictive measure. Role playing is appropriate after the child's anger is defused. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

19. A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts. The nurse should monitor for which desired behavior? a. Increased expressiveness in communication with others b. Abilities to identify anxiety and implement self-control strategies c. Improved abilities to participate in cooperative play with other children d. Tolerates social interactions for short periods without disruption or frustration

ANS: C The goal is improvement in the child's hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

5. What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for attention deficit hyperactivity disorder (ADHD)? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

ANS: C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Disturbed personal identity related to acting out as evidenced by prostitution b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents c. Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another

ANS: C The patient demonstrates a failure to follow age-appropriate social norms and an inability to problem solve by using adaptive behaviors to meet life's demands and roles. The defining characteristics are not present for the other nursing diagnoses. The patient never mentioned hopelessness or disturbed personal identity. The problem relates to the patient's perceptions of parental behavior rather than the actual behavior. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

18. Assessment data for a 7-year-old reveals an inability to take turns, blurting out answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors? a. Disobedience b. Hyperactivity c. Impulsivity d. Anxiety

ANS: C These behaviors are most directly related to impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is demonstrated by failure to listen. Defiance is demonstrated by willfully doing what an authority figure has said not to do. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

22. The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

ANS: C Tics are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

23. When a 5-year-old is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will do what? a. go to a quiet room until called for the next activity. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

ANS: C Time-out is designed so that staff can be consistent in their interventions. Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

12. A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? a. Therapeutic relationships provide an outlet for tension. b. Focusing on the strengths increases a person's self-esteem. c. Acceptance and trust convey feelings of security to the child. d. The child should express feelings rather than internalize them.

ANS: C Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

4. Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? (Select all that apply.) a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

ANS: C, D, E PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will (Select all that apply.) a. graduate from high school. b. live independently in an apartment. c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

ANS: C, D, E Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

22. A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

ANS: D PTSD precipitates changes that can lead to divorce. It is important to provide support to both the veteran and spouse. Confrontation will not be effective. While it is important to provide information, on-going support will be more effective. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? a. visiting their child's grave daily. b. maintaining their child's room as the child left it 2 years ago. c. keeping a place set for the dead child at the family dinner table. d. throwing flowers on the lake at each anniversary date of the accident.

ANS: D Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

10. To plan effective care for clients diagnosed with somatic symptom disorders, the nurse should understand that clients have difficulty giving up the symptoms because of what fact? a. They are generally chronic. b. They have a physiological basis. c. They can be voluntarily controlled. d. They provide relief from health anxiety.

ANS: D At the unconscious level, the client's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the client more psychologically comfortable and may also provide secondary gain, clients frequently fiercely cling to the symptoms. The symptoms tend to be chronic, but that does not explain why they are difficult to give up. The symptoms are not under voluntary control or physiologically based. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

13. A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? a. has occasional toileting accidents. b. interrupts or intrudes on others. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

ANS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent's behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. Conduct disorder (CD)

ANS: D CDs are manifested by a persistent pattern of behavior in which the rights of others and age-appropriate societal norms are violated. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. Criteria for ADHD and PTSD are not met in the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

7. The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for which disorder? a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder (ADHD).

ANS: D Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. A client with fears of serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The client says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)

ANS: D Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a serious disease even when evidence to the contrary is available. The preoccupation causes impairment in social or occupational functioning. Somatic symptom disorder involves fewer symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a personality disorder in which the individual has little regard for the rights of others. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. What is the correct etiology to complete this nursing diagnosis for a client diagnosed with dissociative identity disorder? a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

ANS: D Nearly all clients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? a. visiting their teenager's grave daily. b. returning immediately to employment. c. discussing the accident within the family only. d. creating a scholarship fund at their child's high school.

ANS: D Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

21. Which child demonstrates behaviors indicative of a neurodevelopmental disorder? a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling b. A 9-month-old who does not eat vegetables and likes to be rocked c. A 3-month-old who cries after feeding until burped and sucks a thumb d. A 3-year-old who is mute, passive toward adults, and twirls while walking

ANS: D Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. ASD is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child's plan of care will be provided by an advanced practice nurse rather than a staff nurse? a. Leading an activity group b. Providing positive feedback c. Formulating nursing diagnoses d. Dialectical behavioral therapy (DBT)

ANS: D The advanced practice nurse role includes individual, group, and family psychotherapist; educator of nurses, other professions, and the community; clinical supervisor; consultant to professional and nonprofessional groups; and researcher. DBT is an aspect of psychotherapy. The distracters describe actions of a nurse generalist. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

6. A 12-year-old has engaged in bullying for several years. The parents say, "We can't believe anything our child says." Recently this child shot a dog with a pellet gun and set fire to a neighbor's trash bin. The child's behaviors support which diagnosis? a. Attention-deficit/hyperactivity disorder (ADHD) b. Intermittent explosive disorder. c. Oppositional defiant disorder (ODD). d. Conduct disorder (CD)

ANS: D The behaviors mentioned are most consistent with criteria for CD, including aggression against people and animals; destruction of property; deceitfulness; rule violations; and impairment in social, academic, or occupational functioning. Intermittent explosive disorder is a pattern of behavioral outbursts characterized by an inability to control aggressive impulses in adults 18 years and older. The behaviors are not consistent with attention deficit or oppositional defiant disorder (ODD). PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

14. A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" What is the nurse's best response? a. "Ask the teacher to let the child call you at play time." b. "Withdraw the child from preschool until maturity increases." c. "Remain with your child for the first hour of preschool time." d. "Give your child a kiss before you leave the preschool program."

ANS: D The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

9. A nurse assessing a client diagnosed with a somatic symptom disorder is most likely to note which client characteristic? a. sees a relationship between symptoms and interpersonal conflicts. b. has little difficulty communicating emotional needs to others. c. rarely derives personal benefit from the symptoms. d. has altered comfort and activity needs.

ANS: D The client frequently has altered comfort and activity needs associated with the symptoms displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and security needs may also be compromised. The client is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Clients with somatic symptom disorders often derive secondary gain from their symptoms and/or have considerable difficulty identifying feelings and conveying emotional needs to others. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. What is the nurse's most therapeutic response? a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

ANS: D The client is expressing feelings related to the loss, and this is an expected and healthy behavior. This client is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the client's expression of feelings. Crying at 2 weeks after his death is expected and normal. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

18. A soldier returned 3 months ago from a combat zone and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

ANS: D The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. A child diagnosed with attention deficit hyperactivity disorder (ADHD) had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? a. has an improved ability to identify anxiety and use self-control strategies b. has increased expressiveness in communication with others. c. shows increased responsiveness to authority figures. d. engages in cooperative play with other children.

ANS: D The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

17. What is an essential difference between somatic symptom disorders and factitious disorders? a. Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. b. Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. c. Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.

ANS: D The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

9. When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.

ANS: D The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. An adolescent diagnosed with an impulse control disorder says, "I want to die. I spend my time getting even with people who hurt me." When asked about a suicide plan, the adolescent replies, "I'll jump from a bridge near my home. My father threw kittens off that bridge and they died." What is the client's suicide risk? a. Absent b. Low c. Moderate d. High

ANS: D The suicide risk is high. The child is experiencing feelings of hopelessness and helplessness. The method described is lethal, and the means to carry out the plan are available. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. An older adult client takes multiple medications daily. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What are these findings most characteristic of? a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

ANS: A Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9. An elderly client must be physically restrained. Who is responsible for the client's safety? a. The nurse assigned to care for the client b. Unlicensed assistive personnel who apply the restraint c. Family member who agrees to application of the restraint d. Health care provider who prescribed application of restraint

ANS: A Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the client is responsible for safe application of restraining devices and for providing safe care while the client is restrained. Nurses may delegate the application of restraining devices and the care of the client in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

21. What is the priority intervention for a nurse beginning to work with a client diagnosed with a schizotypal personality disorder? a. Respect the client's need for periods of social isolation. b. Prevent the client from violating the nurse's rights. c. Teach the client how to select clothing for outings. d. Engage the client in community activities.

ANS: A Clients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the client to match clothing is not the priority intervention. Clients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

15. A client diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The client remains impulsive. Which nursing diagnosis is the initial focus of this client's care? a. Self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A The scenario describes self-mutilation. Self-mutilation is a nursing diagnosis relating to client safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the client with borderline personality disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

13. A physically frail elderly client with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this client during the evening and night. Which type of facility should the nurse suggest to meet this client's needs? a. Adult day care program b. Skilled nursing facility c. Partial hospitalization d. Group home

ANS: A A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the client's needs. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

6. A client diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this client? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the client hourly to assess mental status. d. Keep the client by the nurse's desk while awake. Provide rest periods in a room with a television on.

ANS: A A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

12. A client asks, "What is the purpose of having advanced directives?" What is the nurse's best response? a. "It give you control gives your treatment decisions during any illness if you are incapacitated." b. "It can be given only to a relative, usually the next of kin, who has your best interests at heart." c. "It can be used only if you have a terminal illness." d. "The instructions take effect immediately."

ANS: A Advance directives assures that an individual's wishes are considered even if they are unable to make medical decisions. While the instructions in the advanced directive are immediately binding, this is not the best explanation of its purpose. Neither of the remaining options are correct statements. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

27. What is the highest priority for assessment by nurses caring for older adults who self-administer medications? a. The use of multiple drugs with anticholinergic effects. b. The overuse of medications for erectile dysfunction. c. Missing doses of medications for arthritis. d. The trading of medications with acquaintances.

ANS: A Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The distracters may be relevant but are not the highest priority. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

16. Which statement provides the best rationale for closely monitoring a severely depressed client during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Clients who previously had suicidal thoughts need to discuss their feelings. c. For most clients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the client has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

14. A client has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the client to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the client. c. Stimulate intellectual function by discussing new topics with the client. d. Read one story from the newspaper to the client every day.

ANS: A Clients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the client is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the client. Clients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

28. An elderly adult presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

25. An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the client's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The client takes lorazepam on a prn basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the client's drug regime, but interactions are more likely the problem. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. When assessing an elderly client, the nurse should complete the Geriatric Depression Scale if the client answers which question affirmatively. a. "Would you say your mood is often sad?" b. "Are you having any trouble with your memory?" c. "Have you noticed an increase in your alcohol use?" d. "Do you often experience moderate to severe pain?"

ANS: A Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. An older adult client in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful? a. Apply the client's glasses. b. Place personally meaningful objects in view. c. Position large clocks and calendars on the wall. d. Assure that the room is brightly lit but very quiet at all times.

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. Which information is most important to obtain during assessment of an older adult diagnosed with health problems? a. Functional ability and emotional status b. Chronological age and sexual function c. Economic status and sources of income d. Developmental history, interests, and activities

ANS: A Information related to functional ability and emotional status provides an overview of a client's problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance but are not of highest priority since they do not focus on client needs. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the client to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Clients with antisocial personality disorders rarely have feelings of fear and inferiority. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

18. Which assessment findings support a diagnosis of oppositional defiant disorder (ODD)? a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. b. Exhibits involuntary facial twitching and blinking; makes barking sounds. c. Violates others' rights; cruelty toward people or animals; steals; truancy. d. Displays poor academic performance and reports frequent nightmares.

ANS: A ODD is a repeated and persistent pattern of having an angry and irritable mood in conjunction with demonstrating defiant and vindictive behavior. The distracters identify findings associated with conduct disorder (CD), anxiety disorder, and Tourette's syndrome. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

21. Which feeling experienced by a client that should be assessed by the nurse as most predictive of elevated suicide risk? a. hopelessness. b. sadness. c. elation. d. anger.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. A hospitalized client diagnosed with delirium misinterprets reality. A client diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The clients will a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

ANS: A Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Safe, Effective Care Environment

15. In a sad voice, an elderly client tells the nurse of the recent deaths of a spouse and close friend. The client has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this client? a. Risk for suicide related to recent deaths of significant others b. Anxiety related to sudden and abrupt lifestyle changes c. Social isolation related to loss of existing family d. Spiritual distress related to anger with God

ANS: A The client appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The client's social isolation is important, but the risk for suicide has higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

14. A client says, "I get in trouble sometimes because I make quick decisions and act on them." What is the nurse's most therapeutic response? a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

ANS: A The client is showing openness to learning techniques for impulse control. One technique is to teach the client to stop and think before acting impulsively. The client can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

11. It has been 5 days since a suicidal client was hospitalized and prescribed an antidepressant medication. The client is now more talkative and shows increased energy. What is the highest priority nursing intervention? a. Supervise the client 24 hours a day. b. Begin discharge planning for the client. c. Refer the client to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A The client now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The client must be supervised 24 hours per day. The client is still a suicide risk. The other options do not address the client's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

21. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family? a. Label the bathroom door clearly. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 mL/day.

ANS: A The client with moderately severe dementia has memory loss that begins to interfere with activities. This client may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the client in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the client to a urinary tract infection. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

20. What should the goals of care for an older adult client diagnosed with delirium caused by fever and dehydration focus on? a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

ANS: A The desired overall goal is that the delirious client will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a client whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a client with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a client with sensorium problems related to delirium. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Physiological Integrity

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

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The client often feels relieved to be able to talk about suicidal ideation. None of the other options assesses the client's thoughts regarding possible self-harm. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." What does the parents' reaction reflect? a. guilt. b. denial. c. shame. d. rescue feelings.

ANS: A The parents' statements indicate guilt. Guilt is evident from the parents' self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

4. What is the priority nursing diagnosis for a client with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the client is of highest priority among the diagnoses given. Many opportunities for injury exist when a client misperceives the environment as distorted, threatening, or harmful or when the client exercises poor judgment or when the client's sensorium is clouded. The other diagnoses may be concerns but are lower priorities. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Safe, Effective Care Environment

23. A client diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should understand the need to deliver the care in what manner? a. maintaining a stern and authoritarian affect. b. providing care in a matter-of-fact manner. c. encouraging the client to express anger. d. being very rigid but not challenging.

ANS: B A matter-of-fact approach does not provide the client with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include? a. Pain assessment techniques for older adults b. Psychosocial stimulation for those who live alone c. Preparation of psychiatric advance directives in the elderly d. Ways to manage disinhibition in elderly persons with dementia

ANS: A The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly clients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

24. After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

9. What is the priority nursing diagnosis for a client diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

ANS: A Violence against property, along with threats to harm staff, makes this diagnosis the priority. Clients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When clients with antisocial personality disorders use denial, they use it effectively. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Safe, Effective Care Environment

4. Which remarks by a 72-year-old client should prompt the nurse to assess for depression? (Select all that apply.) a. "Lately I have had a lot of aches and pains and just haven't felt very well." b. "People are in and out of my room all day and all night taking my things." c. "Don't ask me to eat. I can't because my stomach is upset all the time." d. "I'm eating more than usual, and I am sleeping about 6 hours a night." e. "Life seems more organized now that I don't live in my own home."

ANS: A, B, C Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? (Select all that apply.) a. Failure of the elderly to receive necessary medical information b. Development of public policy that discriminates against the elderly c. Staff shortages because caregivers prefer working with younger adults d. The perception that elderly consume a smaller share of medical resources e. More ancillary than professional personnel discriminate with regard to age

ANS: A, B, C Because of society's negative stereotyping of the elderly as having little to offer, some staff persons avoid working with older clients. Staff shortages in long-term care are common. Elderly clients are often provided less information about their conditions and fewer treatment options than younger clients are because some health care staff members perceive them as less able to understand. This problem exists among both professional and ancillary personnel. Public policy discriminates against programs for the elderly. Anger exists because the elderly are perceived to consume a disproportionately large share of medical resources. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

2. Which assessment findings would the nurse expect in a client experiencing delirium? (Select all that apply.) a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

ANS: A, B, C Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Clients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. Which nursing interventions will be implemented for a client who is actively suicidal? (Select all that apply.) a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the client's eyeglasses to prevent self-injury. e. Interact with the client every 15 minutes.

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the client to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some clients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the client from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

2. For which clients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

ANS: A, B, C, D Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

1. A nurse assesses five newly hospitalized clients. Which clients have the highest suicide risk? (Select all that apply.) a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

ANS: A, B, D Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A client diagnosed with moderate stage Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the client's plan of care. (Select all that apply.) a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the client's name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the client to proceed independently. e. If the client resists dressing, use distraction and try again after a short interval.

ANS: A, B, E Providing clothing with elastic and hook-and-loop closures facilitates client independence. Labeling clothing with the client's name and the name of the item maintains client identity and dignity (provides information if the client has agnosia). When a client resists, it is appropriate to use distraction and try again after a short interval because client's moods are often labile. The client may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the client to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

3. A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.) a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse assessing an elderly client for depression and suicide potential should include questions about mood as well as for what? (Select all that apply.) a. personal hygiene. b. increased appetite. c. sleep pattern changes. d. evidence of grandiosity. e. increased concerns with bodily functions.

ANS: A, C, E The correct responses relate to symptoms often noted in elderly clients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient's history support the suspected diagnosis? (Select all that apply.) a. Family history of mental illness b. Allergies to multiple antibiotics c. Long history of severe facial acne d. Father with history of alcohol abuse e. History of an abusive relationship with one parent

ANS: A, D, E Parents who are abusive, rejecting, or overly controlling cause a child to suffer detrimental effects. Other stressors associated with impulse control disorders can include major disruptions such as placement in foster care, severe marital discord, or a separation of parents. Substance abuse by a parent is common. Acne and allergies are not aspects of the history that relate to the behavior. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. What is the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills? a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: B The nurse must assess the client's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the client's safety. The information in the other questions may be important to ask but are not the most critical. "Why" question should be avoid since they tend to imply blame. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

6. Which statement about aging provides the best rationale for focused assessment of elderly clients? a. The elderly are usually socially isolated and lonely. b. Vision, hearing, touch, taste, and smell decline with age. c. The majority of elderly clients have some form of early dementia. d. As people age, thinking becomes more rigid and learning is impaired.

ANS: B The only true statement involves the decline of the senses with aging. It cues the nurse to assess sensory function in the elderly client. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

7. Which assessment finding would be likely for a client experiencing a hallucination? a. The client looks at shadows on a wall and says, "I see scary faces." b. The client states, "I feel bugs crawling on my legs and biting me." c. The client reports telepathic messages from the television. d. The client speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A student nurse visiting a senior center says, "It's depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion." The student is expressing what bias? a. reality. b. ageism. c. empathy. d. vulnerability.

ANS: B Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. A client living in community housing for the elderly says, "I don't go to the senior citizen's club. They play cards and talk about the past because that's all they can do." The nurse analyzes these remarks to represent what client related characteristic? a. failure to achieve developmental tasks. b. thinking associated with ageism. c. hypercritical behavior. d. paranoid thinking.

ANS: B Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of ageism as younger individuals. The other options are not substantiated by the information given in the scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

19. A nurse assesses four clients between the ages of 70 and 80. Which client has the highest risk for alcohol abuse? a. The client who consumes a glass of wine nightly with dinner. b. The client who began drinking alcohol daily after retirement and says, "A few drinks keep my mind off my arthritis." c. The client who drank socially throughout adult life and continues this pattern, saying "I've earned the right to do as I please." d. The client who abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA).

ANS: B Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe clients with a lower risk for alcohol abuse. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. A 75-year-old client comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important? a. Complete a neurological assessment. b. Determine whether the client can hear as the nurse speaks. c. Suggest that the client lie down in a darkened room for a few minutes. d. Administer medication to relieve the client's pain before continuing the assessment.

ANS: B Before proceeding with any further assessment, the nurse should assess the client's ability to hear questions. Impaired hearing could lead to inaccurate answers. A neurological assessment is appropriate but will not be accurate if the client is unable to participate in the assessment effectively. The need for the other options can be determined until the assessment is completed. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

1. An adult outpatient client diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this client's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this client's history of overdosing, it is important that the medication be as safe as possible in the event of another overdose of prescribed medication. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

5. What is the priority intervention for a client diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

ANS: B Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the client will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the client's safety. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

25. An older adult client was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this client. Which communication strategy will be most helpful? a. Ask questions that can be answered with "yes" or "no." b. Ask clear, simple questions using concrete language. c. Use silence often and let the client take the lead. d. Use open-ended, indirect questions.

ANS: B Communication with individuals with a long history of schizophrenia might be difficult because of the individual's various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed. The nurse needs more information than "yes" or "no" questions will provide. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. During morning care, a nurse asks a client diagnosed with dementia, "How was your night?" The client replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the client's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The client's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

22. Which statement by a depressed client will alert the nurse to the client's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

12. What is the most challenging nursing intervention with clients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

ANS: B Maintaining consistent limits is by far the most difficult intervention because of the client's superior skills at manipulation. Supporting behavioral change and monitoring client safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

13. A client diagnosed as mild stage Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the client cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at the mild stage and progresses in the subsequent stages. This client is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

7. A client diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The client reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Cholinesterase inhibitor

ANS: B Mood stabilizing medications have been effective for many clients with borderline personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for clients who are impulsive. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

28. A nurse and social worker co-lead a reminiscence group for eight old-old and centenarian adults. Which activity is appropriate to include in the group? a. Mild aerobic exercise b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

ANS: B Old-old adults and centenarians are persons 85 to 104 years of age. They were young people during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

24. A nurse plans a staff education program for employees of a senior living community. Which topic has priority? a. Late-onset schizophrenia b. Depression related suicide c. Dementia d. Delirium

ANS: B Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk clients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

19. A nurse counsels the family of a client diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety? a. Apply a medical alert bracelet to the client. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

ANS: B Placing door locks at the top of the door makes it more difficult for the client with dementia to unlock the door because the ability to look up and reach upward is diminished. The client will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the client's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the client leaves the home, but it does not prevent wandering or assure the client's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

23. A client diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

ANS: B Reorientation may seem like arguing to a client with cognitive deficit and increases the client's anxiety. Validating, talking with the client about familiar, meaningful things, and reminiscing give meaning to existence both for the client and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because clients with dementia sometimes become more agitated with reorientation. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. g-aminobutyric acid deficiency

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8. A primary health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should implement what action regarding these prescriptions? a. implement the fluid restriction. b. question the order for restraint. c. transcribe the prescriptions as written. d. assess the resident's bowel elimination.

ANS: B Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

9. Which medication prescribed to clients diagnosed with Alzheimer's disease antagonizes N-methyl-D-aspartate (NMDA) channels rather than cholinesterase? a. Donepezil b. Rivastigmine c. Memantine d. Galantamine

ANS: C Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

24. A nurse set limits while interacting with a client demonstrating behaviors associated with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be documented using what term? a. denial. b. splitting. c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the client is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

23. A client previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? a. Request the information technology manager to verify the client's medical record is secure in the hospital information system. b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. c. Consult the hospital's legal department regarding potential consequences of the event. d. Document a report of a sentinel event in the client's medical record.

ANS: B Support and an opportunity for staff to safely express feelings about the event should occur first. Interventions should help the staff come to terms with the loss and grow because of the incident. Identifying overlooked clues or faulty judgments will provide the groundwork for identifying changes needed in policies and procedures for future clients. Consulting the legal department is not an initial measure. A sentinel event report is not part of the medical record and can be prepared later. The other incorrect options will not control information or would result in unsafe care. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. A 79-year-old adult tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as suggestive of what? a. normal pessimism of the elderly. b. evidence of risks for suicide. c. a call for sympathy. d. normal grieving.

ANS: B The client describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Analysis | Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity

30. A client says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your clients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

ANS: B The client is attempting to manipulate the nurse. Empathetic mirroring reflects back to the client the nurse's understanding of the client's distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the client. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

28. What personality traits are most likely to be documented by a client demonstrating characteristics of an obsessive-compulsive personality disorder (OCPD)? a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

ANS: B The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein b-amyloid. Which diagnosis applies? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed cerebral pathophysiologies are all associated with development of dementia. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

17. An 85-year-old has difficulty walking after a knee replacement. The client tells the nurse, "It's awful to be old. Every day is a struggle. No one cares about old people." What is the nurse's best response? a. "Everyone here cares about old people. That's why we work here." b. "It sounds like you're having a difficult time. Tell me about it." c. "Let's not focus on the negative. Tell me something good." d. "You are still able to get around, and your mind is alert."

ANS: B The nurse uses empathetic understanding to permit the client to express frustration and clarify her "struggle" for the nurse. The distracters block communication. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. Consider these phenomena: accumulation of b-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B The pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

20. A nurse wants to assess for suicidal ideation in an elderly client. What is the best question to begin this assessment? a. "Are there any things going on in your life that would cause you to consider suicide?" b. "What are your beliefs about a person's right to take his or her own life?" c. "Do you think you are vulnerable to developing a depressed mood?" d. "If you felt suicidal, would you tell someone about your feelings?"

ANS: B This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the client. If the client deems suicide unacceptable, no further assessment is necessary. If the client deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

27. An elderly client is admitted with delirium secondary to a urinary tract infection. The family asks whether the client will ever recover. What is the nurse's best response? a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

ANS: B Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

26. Which nursing diagnosis is appropriate to consider for a client diagnosed with any of the personality disorders? a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

ANS: B Without exception, individuals with personality disorders have problems with social interaction with others; hence, the diagnosis of "impaired social interaction." For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to clients with personality disorders; each might apply to selected clinical diagnoses, but not to others. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. Which beliefs by a nurse facilitate provision of safe, effective care for older adult clients? (Select all that apply.) a. Sexual interest declines with aging. b. Older adults are able to learn new tasks. c. Aging results in a decline in restorative sleep. d. Older adults are prone to become crime victims. e. Older adults are usually lonely and socially isolated.

ANS: B, C, D Myths about aging are common and can negatively impact the quality of care older clients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

3. Which assessment findings would alert the nurse that an older client may have an increased risk for development of geriatric alcohol abuse? (Select all that apply.) a. Mild recent memory impairment b. Eighth grade education c. Death of spouse d. Retirement e. Loneliness

ANS: B, C, D, E The geriatric problem drinker begins drinking in later life, often in response to stressors such as retirement, loss of spouse, and loneliness. Once the demands of job, career, and care of a family and household are gone, the structure of daily life is disrupted. Mild cognitive impairment is not a predisposing factor in the development of geriatric problem drinking. Other risk factors include less than a high school education, smoking, low income, and male gender. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Why is establishing rapport with this adolescent is a priority? (Select all that apply.) a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent. e. adolescents usually relate better to authority figures than peers.

ANS: B, D Trust is frequently an issue because the adolescent may never have had a trusting relationship with an adult. Trust promotes feelings of security and is the basis of the nurse's therapeutic use of self. Adolescents value peer relationships over those related to authority. Rewards for appropriate behavior are the main component of behavior modification programs. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. What are the primary distinguishing factors between the behavior of persons diagnosed with oppositional defiant disorder (ODD) and those with conduct disorder (CD)? The person diagnosed with (Select all that apply.) a. The person diagnosed with ODD relives traumatic events by acting them out. b. The person diagnosed with ODD tests limits and disobeys authority figures. c. The person diagnosed with ODD has difficulty separating from loved ones. d. The person diagnosed with CD uses stereotypical or repetitive language. e. The person diagnosed with CD often violates the rights of others.

ANS: B, E Persons diagnosed with ODD are negativistic, disobedient, and defiant toward authority figures without seriously violating the basic rights of others, whereas persons with CD frequently behave in ways that do violate the rights of others and age-appropriate societal norms. Reliving traumatic events occurs with PTSD. Stereotypical language behaviors are seen in persons with autism spectrum disorders. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. When a client diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the client's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the client's behavior.

ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the client is able to behave appropriately. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

17. An adolescent diagnosed with a conduct disorder (CD) stole and wrecked a neighbor's motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent's reaction? a. Serotonin dysregulation and increased testosterone activity impair one's capacity for remorse. b. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

ANS: C Adolescents with CD have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the amygdala. This reduction may be related to aggressive behavior and deficits of empathy. The less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. People with intermittent explosive disorder may have differences in serotonin regulation in the brain and higher levels of testosterone. Neuron destruction in the hippocampus is associated with memory deficits. The occipital lobe is involved with visual stimuli but not the processing of emotions. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

11. An advance directive gives legally binding direction for health care interventions when a client presents with what scenario? a. has a new diagnosis of cancer. b. is diagnosed with Parkinson's disease. c. is unable to make decisions for self because of illness. d. diagnosed with amyotrophic lateral sclerosis is unable to speak.

ANS: C Advance directives are invoked when clients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson's disease does not mean the client is unable to make a decision. For a client with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

10. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

ANS: C Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

5. Consider this comment to three different nurses by a client diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be documented using which term? a. seductive. b. detached. c. manipulative. d. guilt-producing.

ANS: C Clients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The client is displaying the opposite of detached behavior. Guilt is not evident in the comments. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

ANS: C Clients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

16. When making a distinction as to whether an elderly client is experiencing confusion related to delirium or another problem, what information would be of particular value? a. Evidence of spasticity or flaccidity b. The client's level of motor activity c. Medications the client has recently taken d. Level of preoccupation with somatic symptoms

ANS: C Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

29. A nurse gives anticipatory guidance to the family of a client diagnosed with mild early stage Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

ANS: C Families should be made aware that the client will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the client's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

ANS: C Frequent team meetings are held to counteract the effects of the client's attempts to split staff and set them against one another, causing interpersonal conflict. Clients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

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

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

11. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Sundowning b. Early c. Middle d. Late

ANS: C In the middle stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the late stage there is severe cognitive decline along with agraphia, hyperorality, blunting of emotions, visual agnosia, and hypermetamorphosis. Sundowning is not a stage of Alzheimer's disease. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

10. A new nurse asks the nurse manage, "My elderly client's CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?" What is the best response from the nurse manager? a. "Ask the client's family if they think the client is experiencing pain." b. "Use a visual analog scale to help the client determine the presence and severity of pain." c. "There are special scales for assessing clients with dementia. Let's review how to use them." d. "The perception of pain is diminished by this type of dementia. Focus your assessment on the client's mental status."

ANS: C Lewy bodies associated with dementia [Faculty note: Lewy bodies are defined and addressed in Chapter 23]. There are special scales to assess the presence and severity of pain in clients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A client with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

6. Which behavior demonstrated by that a client diagnosed with an antisocial personality disorder most clearly warrants limit setting? a. Flattering the nurse b. Lying to other clients c. Verbal abuse of another client d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the client's behavior affects the rights of others. Limiting verbal abuse of another client is a priority intervention and particularly relevant when interacting with a client diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

22. Discharge planning begins for an elderly client hospitalized for 2 weeks diagnosed with major depressive disorder. The client needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The client lives with a daughter, who works during the week. Hat is the best referral for this client? a. Behavioral health home care b. A skilled nursing facility c. Partial hospitalization d. A halfway house

ANS: C Partial hospitalization will provide services the client needs as well as give supervision and meals to the client while the daughter is at work. Home care would not provide socialization. The client does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

16. Which statement made by a client diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

15. Two clients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other client turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both clients. b. Reinforce reality. Say to the clients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the clients. Take one to the day room and the other to an activities area. d. Step between the two clients and say, "Please quiet down. We do not allow violence here."

ANS: C Separating and distracting prevents escalation from verbal to physical acting out. Neither client loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening clients is an unsafe action and trying to reinforce reality during an angry outburst will probably not be successful when the clients are cognitively impaired. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

7. A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

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

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. A nurse uses the SAD PERSONS scale to interview a client. This tool provides data relevant to be used for assessing what? a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

29. A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group? a. Mild aerobic exercise b. Singing a song from World War II c. Discussing national leadership during the Vietnam War d. Identifying the most troubling story in today's newspaper

ANS: C Young-old adults are persons 65 to 75 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

2. A client with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the client experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The client feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

11. One month ago, a client diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the client telephones to say, "I feel empty and want to hurt myself." The nurse should immediately take what action? a. Arrange for emergency inpatient hospitalization. b. Send the client to the crisis intervention unit for 8 to 12 hours. c. Assist the client to choose coping strategies for triggering situations. d. Advise the client to take an antianxiety medication to decrease the anxiety level.

ANS: C The client has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the client to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the client is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the client's ability to weigh alternatives to mutilating behavior. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

26. An elderly client brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse's priority action? a. Dispose of all medications that are not in properly labeled bottles. b. Confer with a family member about the client's management of medication. c. Engage the client in education about safe storage and labeling of medication. d. Ask the client to name the purpose and date of expiration of each medication not in a bottle.

ANS: C The client needs medication education and help with proper, safe, and consistent labeling of medications. There is no evidence that the client cannot self-administer medication. The nurse does not have the authority to dispose of the client's property. The nurse would first need to obtain the client's consent to confer with family. While the client may be able to name the purpose of each unbottled medication, naming the expiration date is unlikely and may frustrate the client. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

27. A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? a. A client diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the client remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

ANS: C The client with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. A nurse and client are discussing the client's need to agree not to harm themselves. What is the preferable wording from the client? a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the client who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A client may call a therapist and leave the telephone to carry out the suicidal plan. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. A nurse interacts with an outclient client who has a history of multiple suicide attempts. What is the most helpful response for a nurse to make when the client states, "I am considering committing suicide."? a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

ANS: C The correct response gives the client reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the client's ambivalence and sets the stage for more realistic problem solving. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

13. The history shows that a newly admitted client is impulsive. The nurse would expect the client to demonstrate what characteristic behavior? a. Adherence to a strict moral code. b. Manipulative, controlling strategies. c. Acting without thought on urges or desires. d. Postponing gratification to an appropriate time.

ANS: C The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. As a nurse prepares to administer medication to a client diagnosed with a borderline personality disorder, the client says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the client. Leave the medication on the table as requested. b. Respond to the client, "I'm worried that you might not take it. I'll come back later." c. Say to the client, "I must watch you take the medication. Please take it now." d. Ask the client, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the client's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

4. What is an appropriate initial outcome for a client diagnosed with a personality disorder who frequently manipulates others? a. The client will identify when feeling angry. b. The client will use manipulation only to get legitimate needs met. c. The client will acknowledge manipulative behavior when it is called to his or her attention. d. The client will accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The client would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

13. A tearful, anxious client at the outpatient clinic reports, "I should be dead." What is the initial task the nurse conducting the assessment interview should implement? a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the client. d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the client's suicide as being a way to "fix everything" but does not say it outright. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. Which nursing diagnoses are most applicable for a client diagnosed with severe late stage Alzheimer's disease? (Select all that apply.) a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

ANS: C, D, E The correct answers are consistent with problems frequently identified for clients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The client's cognition is too impaired to grieve. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Diagnosis | Nursing Process: Analysis MSC: Client Needs: Psychosocial Integrity

3. What is the best comment for a nurse to begin an interview with an elderly client? a. "I am a nurse. Are you familiar with what nurses do?" b. "Hello. I am going to ask you some questions to get to know you better." c. "You look comfortable and ready to participate in an admission interview. Shall we get started?" d. "Hello. My name is and I am a nurse. How you would like to be addressed by staff?"

ANS: D The correct opening identifies the nurse's role and politely seeks direction for addressing the client in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the client. The nurse should address clients by name and not assume clients want to be called by a first name. The nurse should always introduce self. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. For which client behavior would limit setting be most essential? a. The client who clings to the nurse and asks for advice about inconsequential matters. b. The client who is flirtatious and provocative with staff members of the opposite sex. c. The client who is hypervigilant and refuses to attend unit activities. d. The client who urges a suspicious client to hit anyone who stares.

ANS: D This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other clients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a client who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to client compliance. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

3. A client with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

ANS: D When hallucinations are present, the nurse should acknowledge the client's feelings and state the nurse's perception of reality, but not argue. Staying with the client increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the client's perception without offering help does not support the client emotionally. Telling the client to relax makes the client responsible for self-soothing. Telling the client that someone will brush the bugs away supports the perceptual distortions. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. A client diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the client misinterpreted the telephone ringing. Which problem is this client experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

ANS: D Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

22. A client diagnosed with borderline personality disorder (BPD) self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to which trigger? a. An inherited disorder that manifests itself as an incapacity to tolerate stress. b. Use of projective identification and splitting to bring anxiety to manageable levels. c. A constitutional inability to regulate affect, predisposing to psychic disorganization. d. Fear of abandonment associated with progress toward autonomy and independence.

ANS: D Fear of abandonment is a central theme for most clients with borderline personality disorder. This fear is often exacerbated when clients with borderline personality disorder experience success or growth. None of the other options is generally a trigger for those diagnosed with BPD) PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Evaluation MSC: Client Needs: Safe, Effective Care Environment

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

ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

24. What is the priority need for a client diagnosed with severe, late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the client from wandering d. Maintenance of nutrition and hydration

ANS: D In severe (late-stage) dementia, the client often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the client is to live. The client is incapable of self-care, ambulation, or verbal communication. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include what characteristics? a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

ANS: D Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

1. A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money." These statements support what client characteristic? a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The client's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. A 76-year-old is indifferent and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization? a. Orientation b. Activity group c. Psychotherapy d. Reminiscence

ANS: D Reminiscence therapy in a group setting can help to re-socialize regressed and apathetic clients. The nurse can encourage discussion about past pleasant events or memories: first car, favorite memory from school, favorite band or song, seasonal activities growing up, etc. Assisting to evoke pleasant feelings or memories is an effective method to improve mood particularly in those with memory impairment. Group psychotherapy would not be effective for this client because of their disinterest in interacting with others. An activity group does not address the client's problem. Orientation groups can exacerbate a client's distress. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

29. A nurse determines desired outcomes for a client diagnosed with schizotypal personality disorder. What is the best outcome? a. The client will adhere willingly to unit norms. b. The client will report decreased incidence of self-mutilative thoughts. c. The client will demonstrate fewer attempts at splitting or manipulating staff. d. The client will demonstrate ability to introduce self to a stranger in a social situation.

ANS: D Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD (Personality Disorder) usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. What is the initial outcome for this client? a. verbalizing a will to live by the end of the second hospital day. b. describing two new coping mechanisms by the end of the third hospital day. c. accurately delineating personal strengths by the end of first week of hospitalization. d. exercising suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

17. When preparing to interview a client diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include which characteristics? a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

ANS: D The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in clients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Clients with dependent personality disorder often express difficulty being alone and are indecisive and submissive. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

ANS: D The nurse helps the client develop effective coping skills. Assist the client to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

8. A client's spouse filed charges after repeatedly being battered. Which statement by this person supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

ANS: D The person with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Persons with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are commonly observed with other psychiatric conditions. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

22. An older client diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this client recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

ANS: D Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in clients with dementia. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

ANS: D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal client b. Referral of a formerly suicidal client to a support group c. Suicide precautions for 24 hours for newly admitted clients d. Helping school children learn to manage stress and be resilient

ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

21. A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, "I get lonely and drink a little to help me forget." What is the nurse's most therapeutic intervention? a. Assess whether this client is drinking and driving. b. Advise the person not to drink alone because the risks for injury increase. c. Teach the person about risks for alcoholism and suggest other coping strategies. d. Arrange for the person to attend an AA meeting for older adults.

ANS: D This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

9. The nurse who is counseling a client with dissociative identity disorder should understand that which assessment is of the highest priority? a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

ANS: A Assessments that relate to client safety take priority. Clients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury. The other options are important assessments but rank below safety. Treatment motivation, while an important consideration, is not necessarily a part of the nursing assessment. PTS: 1 DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

25. How do relaxation techniques help clients who have experienced major traumas? a. By engaging the parasympathetic nervous system. b. By increasing sympathetic stimulation. c. By increasing their metabolic rate. d. By releasing hormones.

ANS: A In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity