Mental Health Exam Unit 5- Final

A school nurse provides education on drug abuse to a high school class. This nursing action is an example of which level of preventive care? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Primary intervention

ANS: 1 Rationale: Providing nursing education on drug abuse to a high school class is an example of primary prevention. Primary prevention services are aimed at reducing the incidence of mental health disorders within the population.

A son, who recently brought his extremely confused parent to a nursing home for admission, reports feelings of guilt. Which is the appropriate nursing response? 1. "Support groups are held here on Mondays for children of residents in similar situations." 2. "You did what you had to do. I wouldn't feel guilty if I were you." 3. "Support groups are available to low-income families." 4. "Your parent is doing just fine. We'll take very good care of him."

ANS: 1 Rationale: The most appropriate response by the nurse is to offer support to the son by presenting available support groups. Caregivers can often experience negative emotions and guilt. Release of these emotions can serve to prevent caregivers from developing psychopathology such a depression.

An older client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which therapeutic intervention should a nurse anticipate will be ordered for this client? 1. Electroconvulsive therapy (ECT) 2. Neuroleptic therapy 3. An antiparkinsonian agent 4. An anxiolytic agent

ANS: 1 Rationale: The nurse should anticipate that ECT will be ordered to treat this client's symptoms of depression. ECT remains one of the safest and most effective treatments for major depression in older adults. The response to ECT may be slower in older clients, and the effects may be of limited duration.

A nurse assesses an adolescent client diagnosed with conduct disorder who, at the age of 8, was sentenced to juvenile detention. How should the nurse interpret this assessment data? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and, therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: 1 Rationale: The nurse should determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.

Which assessment data should a school nurse recognize as a sign of physical neglect? 1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.

ANS: 1 Rationale: The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's syndrome? 1. Neuroleptic medications 2. Anti-manic medications 3. Tricyclic antidepressant medications 4. Monoamine oxidase inhibitor medications

ANS: 1 Rationale: The nurse should recognize that neuroleptic (antipsychotic) medications are effective in the treatment of Tourette's syndrome. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy.

A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is necessary? 1. "In this culture, the color red is associated with death and is considered bad luck." 2. "In this culture, there is an innate fear of death." 3. "In this culture, emotions are not expressed openly." 4. "In this culture, death and bereavement are centered on ancestor worship."

ANS: 1 Rationale: The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck in the Chinese culture. Chinese Americans consider the color white as associated with death and is considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death.

After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? 1. The pharmacological action of Ritalin causes a decrease in appetite. 2. Hyperactivity seen in ADHD causes increased caloric expenditure. 3. Side effects of Ritalin cause nausea, and, therefore, caloric intake is decreased. 4. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: 1 Rationale: The pharmacological action of Ritalin causes a decrease in appetite, which often leads to weight loss. Methylphenidate is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability.

A nursing instructor presents a case study in which a three-year-old child is in constant motion and is unable to sit still during story time. She asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? 1. "This child's behavior must be evaluated according to developmental norms." 2. "This child has symptoms of attention deficit-hyperactivity disorder." 3. "This child has symptoms of the early stages of autistic disorder." 4. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: 1 Rationale: The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. The DSM-5 indicates that emotional problems exist if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

Which of the following should a nurse identify as stressors in the lives of military spouses and children? (Select all that apply.) 1. Frequent moves 2. School credit transfer issues 3. Complications of spousal employment 4. Spousal loneliness 5. Loss of military privileges during spousal deployment

ANS: 1, 2, 3, 4 Rationale: The lives of military spouses and children are clearly affected when the service-member's active duty assignments require frequent family moves. These include, among others, school credit transfer issues, complications of spousal employment, and spousal loneliness. Military privileges are not lost during spousal deployment.

In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (Select all that apply.) 1. It often takes several attempts before a woman leaves an abusive situation. 2. Substance abuse is a common factor in abusive relationships. 3. Until children reach school age, they are usually not affected by abuse between their parents. 4. Women in abusive relationships usually feel isolated and unsupported. 5. Economic factors rarely play a role in the decision to stay.

ANS: 1, 2, 4 Rationale: When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

A nurse is leading a bereavement group. Which of following members of the group should the nurse identify as being at high risk for complicated grieving? (Select all that apply.) 1. A widower who has recently experienced the death of two good friends 2. A man whose wife died suddenly after a cerebrovascular accident 3. A widow who removed life support after her husband was in a vegetative state for a year 4. A woman who had a competitive relationship with her recently deceased brother 5. A young couple whose child recently died of a genetic disorder

ANS: 1, 2, 4, 5 Rationale: The nurse should identify that individuals are at a high risk for complicated grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individual's physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. Having a year to process grief while her husband was in a vegetative state would reduce the widow's risk for the problem of complicated grieving.

Which of the following have been assessed as the most common types of mental illness identified among homeless individuals? (Select all that apply.) 1. Schizophrenia 2. Body dysmorphic disorder 3. Antisocial personality disorder 4. Neurocognitive disorder 5. Conversion disorder

ANS: 1, 3, 4 Rationale: A number of studies have been conducted, primarily in large, urban areas, which have addressed the most common types of mental illness identified among homeless individuals. Schizophrenia is frequently described as the most common diagnosis. Other prevalent disorders include bipolar disorder, substance abuse and dependence, depression, personality disorders, and neurocognitive disorders.

Which of the following types of care should the interdisciplinary team of hospice provide? (Select all that apply.) 1. Physical care available on a 24/7 basis 2. Counseling on the addictive properties of pain-management medications 3. Discussions related to death and dying 4. Explorations of new aggressive treatments 5. Assistance with obtaining spiritual support and guidance

ANS: 1, 3, 5 Rationale: The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying and their families.

A student nurse asks the instructor, "Which psychiatric disorder is most likely initially diagnosed in the elderly?" Which instructor response gives the student accurate information? 1. "Schizophrenia is most likely diagnosed later in life." 2. "Major depressive disorder is most likely diagnosed later in life." 3. "Phobic disorder is most likely diagnosed later in life." 4. "Dependent personality disorder is most likely diagnosed later in life."

ANS: 2 Rationale: Major depressive disorder is most likely to be identified later in life. Depression among older adults can be increased by physical illness, functional disability, cognitive impairment, and loss of a spouse.

A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? 1. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." 2. "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." 3. "Reminiscence therapy is a social group where members chat about past events and future plans." 4. "Reminiscence therapy encourages members to share positive memories of significant life transitions."

ANS: 2 Rationale: Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution. Stimulation of life memories serve to help older clients work through their losses and maintain self-esteem. Reminiscence therapy can take place in one-on-one or group settings.

A client diagnosed with schizophrenia is hospitalized owing to an exacerbation of psychosis related to non-adherence with antipsychotic medications. Which level of care does the client's hospitalization reflect? 1. Primary prevention level of care 2. Secondary prevention level of care 3. Tertiary prevention level of care 4. Case management level of care

ANS: 2 Rationale: The client's hospitalization reflects the secondary prevention level of care. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

A nursing instructor is teaching about case management. What student statement indicates that learning has occurred? 1. "Case management is a method used to achieve independent client care." 2. "Case management provides coordination of services required to meet client needs." 3. "Case management exists mainly to facilitate client admission to needed inpatient services." 4. "Case management is a method to facilitate physician reimbursement."

ANS: 2 Rationale: The instructor evaluates that learning has occurred when a student defines case management as providing coordination of services required to meet client needs. Case management strives to organize client care so that specific outcomes are achieved within allotted time frames.

A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the client's description of the violent rape event. 3. Meet the client's self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.

ANS: 2 Rationale: The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

A child has been diagnosed with autistic spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing response is most appropriate? 1. "Researchers really don't know what causes autistic spectrum disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autistic spectrum disorder. Research has shown that abnormalities in brain structure or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of autistic spectrum disorder than the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic spectrum disorder. Did you breastfeed or bottle-feed?"

ANS: 2 Rationale: The most appropriate response by the nurse is to explain to the parent that autistic spectrum disorder is believed to be caused by abnormalities in brain structure or function, not poor parenting. Autism occurs in approximately 11.3 per 1,000 children and is about 4.5 times more likely to occur in boys than girls.

An older, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate? 1. The client will honestly reveal the nature of the injuries. 2. The client may deny or minimize the injuries. 3. The client may have forgotten what caused the injuries. 4. The client will ask to be placed in a nursing home.

ANS: 2 Rationale: The nurse should anticipate that the client may deny or minimize the injuries. The older client may be unwilling to disclose information, because of fear of retaliation, embarrassment about the existence of abuse in the family, protectiveness toward a family member, or unwillingness to bring about legal action.

A client is diagnosed with terminal cancer. Which situation represents Kübler-Ross's grief stage of "anger"? 1. The client registers for an iron-man marathon to be held in 9 months. 2. The client is a devout Catholic but refuses to attend church and states that his faith has failed him. 3. The client promises God to give up smoking if allowed to live long enough to witness a grandchild's birth. 4. The client gathers family in order to plan a funeral and make last wishes known.

ANS: 2 Rationale: The nurse should assess that the client is in the "anger" stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross's grief process, in which the reality of the situation is realized, and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.

Which is the most accurate description of the nursing diagnosis of dysfunctional grieving? 1. Inability to form a valid appraisal of a loss and to use available resources 2. The experience of distress, with accompanying sadness, which fails to follow norms 3. A perceived lack of control over a current loss situation 4. Aloneness perceived as imposed by others and as a negative or threatening state

ANS: 2 Rationale: The nurse should define dysfunctional grieving as the experience of distress, with accompanying sadness, which fails to follow norms. Three types of pathological grief reactions are delayed or inhibited grief, distorted (exaggerated) grief response, and chronic or prolonged grieving. One crucial difference between normal and dysfunctional grieving is the loss of self-esteem marked my feelings of guilt or worthlessness that may precipitate depression.

Which finding should a nurse expect when assessing a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother is diagnosed with an anxiety disorder. 3. The child previously had an extroverted temperament. 4. The child's mother and father have an inconsistent parenting style.

ANS: 2 Rationale: The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which information about this medication should the nurse provide to the parents? 1. If one dose of Ritalin is missed, double the next dose. 2. Administer Ritalin to the child after breakfast. 3. Administer Ritalin to the child just prior to bedtime. 4. A side effect of Ritalin is decreased ability to learn.

ANS: 2 Rationale: The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

ANS: 2 Rationale: The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

Which behavioral approach should a nurse use when caring for children diagnosed with disruptive behavior disorders? 1. Involving parents in designing and implementing the treatment process 2. Reinforcing positive actions to encourage repetition of desirable behaviors 3. Providing opportunities to learn appropriate peer interactions 4. Administering psychotropic medications to improve quality of life

ANS: 2 Rationale: The nurse should reinforce positive actions to encourage repetition of desirable behaviors when caring for children diagnosed with disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

After reporting a sexual assault, a female soldier is diagnosed with a personality disorder. Which of the following consequences may result? (Select all that apply.) 1. Court-martial proceedings 2. Loss of health-care benefits 3. Loss of service-related disability compensation 4. Stigma of a psychiatric diagnosis 5. Service discharge

ANS: 2, 3, 4, 5 Rationale: Some military women who report their sexual assaults are discharged with a psychiatric diagnosis of personality disorder or adjustment disorder. Some of the consequences of this diagnosis are loss of health-care benefits, loss of service-related disability compensation, and the stigma of a psychiatric diagnosis. The report of a sexual assault would not lead to courtmartial proceedings for the victim.

Which of the following findings should a nurse identify that would contribute to a client's development of ADHD? (Select all that apply.) 1. The client's father was a smoker. 2. The client was born 7 weeks premature. 3. The client is lactose intolerant. 4. The client has a sibling diagnosed with ADHD. 5. The client has been diagnosed with dyslexia.

ANS: 2, 4 Rationale: The nurse should identify that premature birth and having a sibling diagnosed with ADHD would predispose a client to the development of ADHD. Research indicates evidence of genetic influences in the etiology of ADHD. Studies also indicate that environmental influences, such as lead exposure and diet, can be linked with the development of ADHD.

A nursing instructor is teaching about the Community Health Centers Act of 1963. What was a deterring factor to the proper implementation of this act? 1. Many perspective clients did not meet criteria for mental illness diagnostic-related groups. 2. Zoning laws discouraged the development of community mental health centers. 3. States could not match federal funds to establish community mental health centers. 4. There was not a sufficient employment pool to staff community mental health centers.

ANS: 3 Rationale: A deterring factor to the proper implementation of the Community Mental Health Centers Act of 1963 was that states could not match federal funds to establish community mental health centers. This act called for the construction of comprehensive community mental health centers to offset the effect of deinstitutionalization, the closing of state mental health hospitals.

Research has shown that an adolescent (13 to18 years) would typically exhibit which behavior as a reaction to parental military deployment? 1. May exhibit regressive behaviors and assume blame for parent's departure. 2. May become sullen, tearful, throw temper tantrums, or develop sleep problems. 3. May participate in high-risk behaviors, sexual acting out, and drug or alcohol abuse. 4. May respond to schedule disruptions with irritability and/or apathy and weight loss.

ANS: 3 Rationale: Infants (birth to 12 months) may respond to schedule disruptions with irritability and/or apathy and weight loss. Toddlers (1 to 3 years) may become sullen, tearful, throw temper tantrums, or develop sleep problems. Preschoolers (3 to 6 years) may regress in areas such as toilet training, sleep, separation fears, physical complaints, or thumb sucking and may assume blame for parent's departure. School age children (6 to 12 years) are more aware of potential dangers to parent. May exhibit irritable behavior, aggression, or whininess. May become more regressed and fearful about parent's safety. Adolescents (13 to 18 years) may be rebellious, irritable, or more challenging of authority. Parents need to be alert to high-risk behaviors, such as problems with the law, sexual acting out, and drug or alcohol abuse.

A nursing instructor is teaching about suicide among active duty military. Which fact should the instructor include in the lesson plan? 1. On average, two suicides a day occur in the U.S. military. 2. From 2005 to 2009, relationship distress factored in more than 25% of Army suicides. 3. Statistically, in 2012, suicide rates of service members surpassed the number killed in combat. 4. Military suicides are associated with a narcissistic personality disorder diagnosis.

ANS: 3 Rationale: On average, one not two suicides a day occur in the U.S. military. From 2005 to 2009, relationship distress factored in more than 50% not 25% of Army suicides. Military suicides are associated with the diagnoses of substance use disorder, major depressive disorder, PTSD, and TBI, not narcissistic personality disorder. Statistically, in 2012, suicide rates of service members surpassed the number killed in combat.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? 1. Phase I: The tension-building phase 2. Phase II: The acute battering incident phase 3. Phase III: The honeymoon phase 4. Phase IV: The resolution and reorganization phase

ANS: 3 Rationale: The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

A newly admitted homeless client diagnosed with schizophrenia states, "I have been living in a cardboard box for two weeks. Why did the government let me down?" Which is an appropriate nursing response? 1. "Your discharge from the state hospital was done prematurely. Had you remained in the state hospital longer, you would not be homeless." 2. "Your premature discharge from the state hospital was not intended for patients diagnosed with chronic schizophrenia." 3. "Your discharge from the state hospital was based on firm principles; however, the resources were not available to make the transition a success." 4. "Your discharge from the state hospital was based on presumed family support, and this was not forthcoming."

ANS: 3 Rationale: The most accurate nursing response is to explain to the client that the resources were not available to make transitioning out of a state hospital a success. There are several factors that are thought to contribute to homelessness among the mentally ill: deinstitutionalization, poverty, lack of affordable housing, lack of affordable health care, domestic violence, and addiction disorders.

. A client in the middle stage of Alzheimer's disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication? 1. Discourage attempts at verbal communication owing to increased client frustration. 2. Increase the volume of the nurse's communication responses. 3. Verbalize the nurse's perception of the implied communication. 4. Encourage the client to communicate by writing.

ANS: 3 Rationale: The most appropriate nursing intervention is to verbalize the nurse's perception of the implied communication. The nurse should also keep explanations simple, use face-to-face interaction, and speak slowly without shouting.

In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day four. 3. The client will establish trust with at least one caregiver by day five. 4. The client will perform most self-care tasks independently.

ANS: 3 Rationale: The most realistic client outcome for a child diagnosed with autistic spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

An older client who lives with a caregiver is admitted to an emergency department with a fractured arm. The client is soaked in urine and has dried fecal matter on lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? 1. Inability for the client to meet self-care needs 2. Alzheimer's disease 3. Abuse and/or neglect 4. Caregiver role strain

ANS: 3 Rationale: The nurse should expect that this client is a victim of elder abuse or neglect. Indicators of elder physical abuse include bruises, fractures, burns, and other physical injury. Neglect may be manifested as hunger, poor hygiene, unattended physical problems, or abandonment.

A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response? 1. "To decrease the victimizer's insecurity." 2. "To inflict physical harm with the weapon." 3. "To terrorize and subdue the victim." 4. "To mirror learned family behavior patterns related to weapons."

ANS: 3 Rationale: The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's ADHD. Which nursing response best addresses the mother's concern? 1. "The physician will probably switch from Ritalin to a central nervous system stimulant." 2. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." 3. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." 4. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: 3 Rationale: The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is a central nervous system stimulant, and tolerance can develop rapidly. Physical and psychological dependence can also occur.

An older client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regime? 1. Altered cortical and intellectual functioning 2. Altered respiratory and gastrointestinal functioning 3. Altered liver and kidney functioning 4. Altered endocrine and immune system functioning

ANS: 3 Rationale: The nurse should question the use of antidepressant medication in a client with altered liver and kidney function. Antidepressant medication should be administered with consideration for age-related physiological changes in absorption, distribution, elimination, and brain receptor sensitivity. Because of these changes, medications can reach high levels despite moderate oral dosage.

A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? 1. Controlled response pattern 2. Compounded rape reaction 3. Expressed response pattern 4. Silent rape reaction

ANS: 3 Rationale: The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

A nurse is implementing care within the parameters of tertiary prevention. Which nursing action is an example of this type of care? 1. Teaching an adolescent about pregnancy prevention 2. Teaching a client the reportable side effects of a newly prescribed neuroleptic medication 3. Teaching a client to cook meals, make a grocery list, and establish a budget 4. Teaching a client about his or her new diagnosis of bipolar disorder

ANS: 3 Rationale: The nurse who teaches a client to cook meals, make a grocery list, and establish a budget is implementing care within the parameters of tertiary prevention. Tertiary prevention consists of services aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning.

A raped client answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this client's responses? 1. The client may be lying about the incident. 2. The client may be experiencing a silent rape reaction. 3. The client may be demonstrating a controlled response pattern. 4. The client may be having a compounded rape reaction.

ANS: 3 Rationale: This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.

When a home health nurse administers an outpatient's injection of haloperidol decanoate (Haldol decanoate), which level of care is the nurse providing? 1. Primary prevention level of care 2. Secondary prevention level of care 3. Tertiary prevention level of care 4. Case management level of care

ANS: 3 Rationale: When administering medication in an outpatient setting, the nurse is providing a tertiary prevention level of care. Tertiary prevention services are aimed at reducing the residual effects that are associated with severe and persistent mental illness. It is accomplished by preventing complications of the illness and promoting rehabilitation that is directed toward achievement of maximum functioning.

When intervening with a married couple experiencing relationship discord, which nursing action reflects an intervention at the secondary level of prevention? 1. Teaching assertiveness skills in order to meet assessed needs 2. Supplying the couple with guidelines related to marital seminar leadership 3. Teaching the couple about various methods of birth control 4. Counseling the couple related to open and honest communication skills

ANS: 4 Rationale: Counseling the couple related to open and honest communication skills is a reflection of a nursing intervention at the secondary level of prevention. Secondary prevention aims at minimizing symptoms and is accomplished through early identification of problems and prompt initiation of effective treatment.

Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? 1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Have ready access to the number of a safe house for battered women.

ANS: 4 Rationale: The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.

A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? 1. The woman may be exhibiting a controlled response pattern. 2. The woman may have a history of childhood neglect. 3. The woman may be exhibiting codependent characteristics. 4. The woman may be a victim of incest.

ANS: 4 Rationale: The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate response? 1. "These clients don't know life any other way, and change is not an option until they have improved insight." 2. "These clients have limited cognitive skills and few vocational abilities to be able to make it on their own." 3. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." 4. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

ANS: 4 Rationale: The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.

A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client? 1. Denial of personal mortality 2. Preoccupation with the loss 3. Clinging behaviors and personal insecurity 4. Acting-out behaviors, exhibited in aggression and defiance

ANS: 4 Rationale: The school nurse should anticipate that the teenager will exhibit aggression and acting out. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to talk with peers about feelings than with other adults.

The ________________________ movement closed state mental hospitals and caused the discharge of individuals with mental illness.

ANS: deinstitutionalization Rationale: The deinstitutionalization movement closed state mental hospitals and caused the discharge of individuals with mental illness. Congress passed the Mental Retardation Facilities and Community Mental Health Centers Construction Act (often called the Community Mental Health Centers Act) in 1963. This act called for the construction of comprehensive community health centers, the cost of which would be shared by federal and state governments. Unfortunately, many state governments did not have the capability to match the federal funds required for the establishment of these mental health centers.

Physical ________________ of a child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision.

ANS: neglect Rationale: Physical neglect of a child includes refusal of or delay in seeking health care, abandonment, expulsion from the home or refusal to allow a runaway to return home, and inadequate supervision. Children are vulnerable and relatively powerless, and the effects of maltreatment are infinitely deep and long lasting.

The DSM-5 criteria for ODD specifies that: A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness must be evident and last at least ______________ months.

ANS: six Rationale: A persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness must be evident and last at least six months according to the DSM-5 criteria for the diagnosis of ODD.

Which grief reaction can the nurse anticipate in a 10-year-old child? a. Statements that the deceased person will soon return. b. Regressive behaviors, such as loss of bladder control. c. A preoccupation with the loss. d. Thinking that they may have done something to cause the death.

c. A preoccupation with the loss.