Mental Health Final Exam
A 7-year-old client experiences tics, which have become increasingly frequent in recent months. How should the nurse educate the client's teacher to respond to the tics? a. set firm limits about where, when, and how the client exhibits the tics. b. teach the client's classmates that the tics are not something that the client can control. c. place the client in a private, low-stimulation environment whenever possible to prevent the client's tics. d. provide rewards when the client goes long periods without having any tics.
b. teach the client's classmates that the tics are not something that the client can control.
A client's history reveals that he continues to use cocaine despite the negative consequences. The nurse identifies this as which of the following? a. Abuse b. Use c. Addiction d. Withdrawal
c. Addiction
A client is brought to the ED following a car accident. The client's blood alcohol level (BAL) is 0.10%. Which of the following would the client likely exhibit? a. Giddiness b. Impaired coordination c. Ataxia d. Emotional lability
b. Impaired coordination
The nurse is assessing a child who is suspected of having Tourette's disorder. The nurse is reviewing the child's history, keeping mind that for the diagnosis to be made, the tics must be present for at least which time frame? a. 1 month b. 6 months c. 1 year d. 2 years
c. 1 year
The nurse is educating a pregnant client about prenatal care and the potential for decreasing the risk for conduct disorder. The client presently has a child with a conduct disorder and is concerned that this will happen again. Which statement made by the client indicates further education is required? a. "As long as I only have a beer or two a couple of times a week, my unborn child will be ok." b. "I should be sure to be adherent to my prescribed prenatal vitamins and folic acid." c. "Prenatal care is important and I will attend all of my visits routinely." d. "There are several factors that are involved for a child to develop a conduct disorder."
a. "As long as I only have a beer or two a couple of times a week, my unborn child will be ok."
A nurse is interviewing a client and suspects an eating disorder. Which client statement would the nurse interpret as demonstrating a risk for the development of an eating disorder? Select all that apply. a. "Everything about my schoolwork needs to be perfect." b. "I want things to be the way I want them to be." c. "I'll stand up for what I want, regardless of what you say." d. "Things being out of order really bothers me." e. "I consider myself a really laid-back individual."
a. "Everything about my schoolwork needs to be perfect." b. "I want things to be the way I want them to be." d. "Things being out of order really bothers me."
A parent informs the nurse that they are concerned that their child might suffer from ADHD. The child cannot sit still, running all over the house, and having difficulty in school. Which is the best response by the nurse? a. "From what you are describing, ADHD may be a possibility, and we will refer you to a specialist for screening." b. "All children can be like that and it may be a disciplinary issue and not a symptom of ADHD." c. "Not all children do well in school, and parents have a very high expectation of achievement." d. "You should be sure to talk to the health care provider about prescribing medication for treatment."
a. "From what you are describing, ADHD may be a possibility, and we will refer you to a specialist for screening."
A client with a tic disorder tells the nurse that they are experiencing more complex motor tics and verbal tics lately but they get better when occupied with a task. Which question will be most appropriate to ask the client to determine the best option for decreasing these symptoms? a. "Have you been experiencing an increase in stress lately?" b. "Is there any changes that you have made to your diet?" c. "Are you taking any new medications?" d. "Have you developed any new allergies?"
a. "Have you been experiencing an increase in stress lately?"
The nurse is assessing a client with anorexia nervosa. Which statement(s) by the client will likely support this diagnosis? Select all that apply. a. "I don't know what the fuss is about, I'm too fat to be a model." b. "I know some friends; I just don't hang out or talk to them." c. "We have a really tight-knit family, always laughing." d. "When I graduate, I'm going to college to be a lawyer." e. "There are a lot of thin people in my family."
a. "I don't know what the fuss is about, I'm too fat to be a model." b. "I know some friends; I just don't hang out or talk to them."
The nurse is talking with an adolescent client who has been externalizing behaviors indicating a conduct disorder. Which client statement(s) indicate that externalizing behaviors are being experienced? a. "I got caught cheating on an exam. I cheat all of the time, why should I study?" b. "I set fire to a trash can on school property when I threw my cigarette in it." c. "When I get dropped off at school, I skip and go drink with my friends." d. "My stomach hurts and I feel nauseated all of the time." e. "I'm always tired and sleepy. Just don't feel like going anywhere or doing things."
a. "I got caught cheating on an exam. I cheat all of the time, why should I study?" b. "I set fire to a trash can on school property when I threw my cigarette in it." c. "When I get dropped off at school, I skip and go drink with my friends."
A psychiatric-mental health nurse is teaching a parent of a child diagnosed with conduct disorder. Which statement made by the parent indicates a need for further teaching? a. "I will suppress my problems and not burden others with what I am going through." b. "I will not try to rescue my child." c. "I will enforce effective limit-setting techniques." d. "I will implement age-appropriate activities and expectations."
a. "I will suppress my problems and not burden others with what I am going through."
The nurse is sitting with the client at mealtime. The nurse uses cognitive-behavioral approaches to assist the client with bulimia toward recovery. Which statement by the nurse would be consistent with this approach? a. "Is there any way you can look at that sandwich as fuel for your body?" b. "You have to eat in moderation for good nutrition." c. "You seem to have a really hard time controlling your eating patterns." d. "Is this your way of showing your family that you can make decisions?"
a. "Is there any way you can look at that sandwich as fuel for your body?"
A nurse is providing care to a child with Tourette disorder. In teaching the patient about the disorder and treatment, what will the nurse teach about the medication? a. "The condition is treated with atypical antipsychotic medication." b. "An antidepressant will be used to treat effects of the disorder." c. "A mood stabilizer will be given for outbursts." d. "A medication used in the treatment of ADHD will be given."
a. "The condition is treated with atypical antipsychotic medication."
After educating the parents of a child diagnosed with ADHD on the disorder and its treatment, the nurse determines that the education has been effective when the parents make which statement? a. "We need to remember that our child is not a bad kid but just has difficulty with impulse control and attention." b. "We need to be careful so our child doesn't develop a substance abuse problem." c. "We should stop the medication after two months to see how effective it is in really controlling symptoms." d. "We should set up regular routines, but not worry if our child violates the limits once in a while."
a. "We need to remember that our child is not a bad kid but just has a difficulty with impulse control and attention."
The nurse is caring for a client with alcohol use disorder that is acutely intoxicated. Which action will the nurse perform to treat the Wernicke-Korsakoff syndrome the client is experiencing? a. Administer Vitamin B1 b. Administer Folic Acid c. Administer Cyanocobalamin d. Administer Naloxone
a. Administer Vitamin B1 Wernicke- thiamine deficiency Korsakoff- syndrome of confusion, loss of recent memory, & confabulation
A patient has a BMI of 16, is noticeably very thin and keeps a journal to monitor all of their intake and output, even going as far as measuring their bowel movements. What would you suspect the diagnosis to be? a. Anorexia nervosa b. Binge-eating c. Obesity d. Bulimia nervosa
a. Anorexia nervosa BMI 17 or less less than 15 will be hospitalized
The nurse is talking with a client that grew up in a home where both parents were alcoholics. Which behavior(s) does the nurse identify when assessing this client that correlate with this home life? Select all that apply. a. Drinks alcohol to excess 3 days a week. b. Several trusting relationships with friends. c. Went back to college to complete a degree in nursing. d. Divorced 3 times with tumultuous relationships with spouses. e. States that they hold on to bad relationships due to fear of being alone.
a. Drinks alcohol to excess 3 days a week. d. Divorced 3 times with tumultuous relationships with spouses. e. States that they hold on to bad relationships due to fear of being alone.
After teaching a group of nursing students about intellectual disability, the instructor determines that the teaching was successful when the students identify which as the most common etiology? a. Genetic syndromes b. Exposure to hazardous chemicals c. Environment d. Perinatal complications
a. Genetic syndromes
What disorder is linked to fetal alcohol syndrome resulted from alcohol use during pregnancy? a. IDD b. Conduct c. Oppositional d. Anxiety
a. IDD
The charge nurse observes another nurse reporting for work looking unkempt and disheveled with uncoordinated movements and breath smelling of alcohol. Which is the priority action by the charge nurse? a. Immediately call the supervisor to report the nurses' behavior. b. Tell the nurse that they are suspected of being intoxicated and to go home. c. Give the nurse information about the hospital's employee assistance program. d. Talk to other employees on the unit to see if anyone else notices the behavior.
a. Immediately call the supervisor to report the nurses' behavior.
Which is considered a hyperactive/impulsive behavior seen in ADHD? a. Inability to play quietly b. Avoiding tasks requiring mental effort c. Making careless mistakes d. Frequent forgetfulness in daily activities
a. Inability to play quietly
Which medication is used to prevent alcohol withdrawal symptoms? a. Lorazepam (Ativan) b. Clonidine (Catapres) c. Folic acid (Folate) d. Naltrexone (ReVia)
a. Lorazepam (Ativan)
A client with a history of alcohol use disorder has presented to the ED with hallucinations and relays being followed by the police. Which action will the nurse take given this information? a. Monitor for Korsakoff syndrome from long-term effects of alcohol use. b. Prepare for lumbar puncture for viral encephalopathy. c. Administer B12 deficiency injection using Z-track method. d. Determine if the client is having episodes of cognitive dementia.
a. Monitor for Korsakoff syndrome from long-term effects of alcohol use.
A patient has been noted to have a negative defiant behavior, including obstinacy, procrastination, disobedience, resistance to change and authority. What is the suspected diagnosis? a. Oppositional defiant disorder b. IDD c. Autism d. Separation anxiety disorder
a. Oppositional defiant disorder
At the prompting of friends, a 16-year-old client has agreed to meet with the school nurse who suspects that the client may have an eating disorder. During the nurse's assessment, the nurse has asked the client to describe the client's family. Which family process and characteristic is thought to contribute to eating disorders? a. Poor communication and enmeshed family dynamics. b. The absence of a parent and/or the presence of a stepparent. c. Passive parenting and lack of encouragement. d. An overemphasis of peer relationships over family relationships.
a. Poor communication and enmeshed family dynamics.
Which of the following approaches is included in milieu management for the child with autism spectrum disorder? a. Providing a structured, routine environment. b. Scheduling a group in which the children talk about school. c. Having a playroom with climbing structures and rolling chairs. d. Listen to the parents feelings and frustrations.
a. Providing a structured, routine environment.
People diagnosed with bulimia nervosa have lower levels of which neurotransmitter? a. Serotonin b. Norepinephrine c. Dopamine d. Acetylcholine
a. Serotonin
A client with alcohol use disorder is admitted for treatment. Which statement indicates that the nurse has an issue with the client's condition? a. "Tell me how you are feeling right now." b. "I have family members with the same problem." c. "Explain to me when you started using alcohol." d. "So you attended Alcoholics Anonymous meetings for how long?"
b. "I have family members with the same problem."
A client with anorexia nervosa describes herself as "a whale". However, the nurse's assessment reveals that the client is 5'8" tall and weighs only 90 lb. When considering the client's unrealistic body image, which intervention should be included in the care plan? a. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy. b. Asking the client to compare her figure with magazine photographs of women her age. c. Assigning the client to group therapy in which participants provide realistic feedback about her weight. d. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift.
a. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy.
When working with a client with bulimia, the nurse should encourage the client to keep a diary or journal for what reason? a. To improve coping through behavioral changes. b. To document evidence of the client's progress. c. To record problems to share with the physician. d. To be read by the nurse to set achievable goals.
a. To improve coping through behavioral changes.
When a client repeatedly vocalizes an obscene phrase and imitates the motions of a staff member, the nurse documents that the client is most likely exhibiting symptoms of what disorder? a. Tourette's syndrome b. Autism spectrum disorder c. Phonological disorder d. Mixed receptive-expressive language disorder
a. Tourette's syndrome
The school nurse is evaluating a 16-year-old student who came to the office complaining of dizziness. The student is very thin and was pacing in the office while waiting to see the nurse. The nurse asks the nurse to step on the scale. The student asks if the student can go to the bathroom first to empty the student's bladder, stating, "That can make a big difference." The student's comment raises the nurse's suspicion that the student has... a. anorexia nervosa b. binge-eating disorder c. bulimia nervosa d. eating disorder not otherwise specified
a. anorexia nervosa
A nurse is assessing a 10-year-old child who is displaying behaviors that are consistent with oppositional defiance disorder. When conducting the assessment, the nurse should also assess for which co-morbidity? a. attention deficit hyperactivity disorder b. schizophrenia c. cognitive impairment d. kleptomania
a. attention deficit hyperactivity disorder
A new nurse asks what the most common risk factor is for a patient with Conduct disorder? a. familial history b. environment c. perinatal factors d. chromosomal involvement
a. familial history
The nurse provides care to an adolescent client who presents to the ED after losing consciousness during a marching band performance. A differential diagnosis of anorexia nervosa is documented by the practitioner. Which finding noted when reviewing the client's lab data indicates a need for hospitalization? a. hypokalemia b. hypoglycemia c. hypermagnesemia d. hyperphosphatemia
a. hypokalemia
An adolescent patient has been diagnosed with IDD. Upon further assessment it is determined that the patient has no capacity for independent functioning with an IQ of 15. What level of IDD would you expect this patient to have? a. profound b. severe c. moderate d. mild
a. profound IQ below 20
A nurse is assessing a child with a suspected intellectual disability. The nurse is evaluating the child's adaptive behavior, focusing on practical skills. Which area would the nurse most likely address? Select all that apply. a. safety b. schedules c. activities of daily living d. self-esteem e. ability to follow rules
a. safety b. schedules c. activities of daily living
When assisting the parents of a child diagnosed with ADHD, which of the following would the nurse suggest? Select all that apply. a. set clear limits with consequences b. provide extensive explanations c. keep to regular routines d. maintain a calm environment e. let him work on several things at once
a. set clear limits with consequences c. keep to regular routines d. maintain a calm environment
A nurse is assessing a child diagnosed with attention deficit hyperactivity disorder. Which of the following would the nurse expect the parents to report? a. "He is always so sad all of the time." b. "He just doesn't seem to want to sit still, ever!" c. "He likes to focus his attention on one thing at a time." d. "He is very methodical when he is working on something."
b. "He just doesn't seem to want to sit still, ever!"
A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse? a. "I am going to take up a new hobby. It's time to start something new." b. "I can still hang out with my old friends. I am just not going to use." c. "I'm not very comfortable with being alone yet." d. "Shooting baskets helps me not think about getting high."
b. "I can still hang out with my old friends. I am just not going to use."
The nurse has been teaching a client about bulimia. Which statement by the client indicates that the teaching has been effective? a. "I know if I eat pasta, I'll binge." b. "I'll eat small meals and snacks regularly." c. "I'll take my medication when I feel the urge to binge." d. "I'll limit my intake of carbohydrates and fats."
b. "I'll eat small meals and snacks regularly."
An 8-year-old with ADHD is jumping off the bed onto a chair. Which response by the nurse would be most appropriate? a. "I need to talk to you." b. "Stop jumping on the bed now." c. "You are going to hurt yourself." d. "Why are you jumping off the bed?"
b. "Stop jumping on the bed now."
A family member of a patient with Alcohol Use Disorder in your clinic expresses the blame and guilt that they feel over the patient. What would be the most appropriate response from the nurse? a. "Everyone feels that way, but you shouldn't feel bad." b. "There is a group called AL-ANON that is for the families of patients for therapy." c. "It will get better, don't worry." d. "I felt the same way about my sibling, just keep your head down and it will all be fine."
b. "There is a group called AL-ANON that is for the families of patients for therapy"
An adolescent child has been brought to your clinic for further evaluation. The parent explains that the child is very impulsive, has a short attention span, highly distractable, disruptive in class, restless and fidgets, and tends to have a low frustration tolerance with temper outbursts. What do you suspect the diagnosis for this patient to be? a. IDD b. ADHD c. OCD d. ASD
b. ADHD
A client is being treated for alcoholism. Which of the following medications would you expect to administer for cessation of alcohol, and must warn the patient that if they were to drink alcohol while taking this medication, it will make them sick? a. Clonidine b. Antabuse c. Folic Acid d. Naltrexone
b. Antabuse
A patient is diagnosed with Conduct disorder. With previous knowledge learned, what other disorder does this tend to lead to? a. ADHD b. Anti-social disorder c. Autism Spectrum Disorder d. IDD
b. Anti-social disorder
A psychiatric-mental health nurse is teaching a client's family about eating disorders. Which aspect of education should be included in the session? a. Take responsibility for making the client eat. b. Avoid only talking about weight, food intake, and calories. c. Understand basic nutritional needs. d. Set realistic goals for eating.
b. Avoid only talking about weight, food intake, and calories.
The nurse is caring for a client with delirium tremens (DTs). Which development constitutes a medical emergency? a. Atrial fibrillation on the monitor. b. Development of seizure activity. c. Jaundice and irritability. d. Urine has a coffee appearance.
b. Development of seizure activity.
The nurse is planning the care for a child with ADHD. When discussing interventions with the parent, which nursing intervention will be the highest priority? a. Provide a structured daily routine. b. Ensure the child's safety due to impulsiveness. c. Simplify instructions and directions with only one step at a time. d. Improve role performance.
b. Ensure the child's safety due to impulsiveness.
A client has been diagnosed with anorexia nervosa. Which of the following is a dental complication associated with purging? a. Seizures b. Erosion of dental enamel c. Elevated BUN d. Enlarged pancreas
b. Erosion of dental enamel
Which characteristic of the 12-step program distinguishes it from other programs? a. The philosophy that is possible to reduce the use of substances without abstaining. b. It is a self-help group that focuses on total abstinence. c. Persons who use this program are independent in their sobriety. d. Infrequent attendance is usually successful.
b. It is a self-help group that focuses on total abstinence.
A client is experiencing severe alcohol withdrawal. Which would the nurse identify during the assessment that correlates with the withdrawal symptoms? Select all that apply. a. Heart rate around 72bpm. b. Marked diaphoresis. c. Auditory hallucinations. d. Gross uncontrollable tremors. e. Increased appetite.
b. Marked diaphoresis. c. Auditory hallucinations. d. Gross uncontrollable tremors.
An 8-year-old boy has been diagnosed with ADHD. His mother is shocked that he will be prescribed a psychostimulant, stating, "His whole problem is that he's too stimulated, not under-stimulated!" Which of the following facts should underlie the nurse's response to the mother? a. Controlled, medication-induced stimulation helps children become more comfortable and functional during times of high stimulation. b. Psychostimulants stimulate the areas of the brain that control attention, impulses, and self-regulation of behavior. c. Brain stimulation is inversely proportionate to motor stimulation. d. Psychostimulants are a form of aversion therapy in which the child becomes uncomfortable with overstimulation.
b. Psychostimulants stimulate the areas of the brain that control attention, impulses, and self-regulation of behavior.
The nurse is working with clients who have disruptive behavior disorders. Which are important point(s) for the nurse to consider when working with these clients and their families? Select all that apply. a. Most behavior disorders are caused by being raised by parents who had behavior disorders in their own childhoods. b. Remember to focus on the client's strengths and assets, as well as their problems. c. Transient conduct disorders are common in all children. d. Avoid a "blaming" attitude toward clients and/or families. e. Focus on positive actions to improve situations and/or behaviors.
b. Remember to focus on the client's strengths and assets, as well as their problems. d. Avoid a "blaming" attitude toward clients and/or families. e. Focus on positive actions to improve situations and/or behaviors.
A new pre-school aged patient is being observed in your clinic. Upon assessment you notice the patient has difficulty when the mother is asked to leave the room, resulting in tantrums of crying and screaming. When you speak to the mother, she reports that the child refuses to attend sleepovers and after starting school the child began having nightmares. With all of this information, what would you suspect to be the diagnosis? a. Autism Spectrum Disorder b. Separation Anxiety Disorder c. Conduct Disorder d. ADHD
b. Separation Anxiety Disorder
A pediatric client diagnosed with ADHD is in the immediate phase of care. Which client outcome would be identified in the immediate phase of care? a. Participate successfully in the educational setting. b. Successfully complete tasks or assignments with assistance within 24 to 36 hours. c. Demonstrate the ability to complete tasks with reminders. d. Verbalize positive statements about themselves.
b. Successfully complete tasks or assignments with assistance within 24 to 36 hours.
The parent of a 6-year-old child with Autism Spectrum Disorder (ASD) informs the nurse that the temper tantrums are getting difficult to control and the parents is afraid of what the child will do to themself and other family members. Which option will the nurse discuss with the parent to help manage the behaviors? a. These behaviors are difficult to manage, but they will get better as the child ages. b. The use of antipsychotic medications may be helpful with the tantrums and aggression. c. The parent will need to take a firmer disciplinary approach with the child. d. The child may require inpatient care since this is not a typical behavior of ASD.
b. The use of antipsychotic medications may be helpful with the tantrums and aggression.
A family with a child who has a conduct disorder tells the nurse they are increasingly frustrated in their attempts to make things better at home. What suggestion(s) should the nurse make that would lead to decreased frustration? Select all that apply. a. Provide rewards instead of punishments for problematic behavior. b. Try to think of alternative responses to the child's behavior. c. Offer role-playing scenarios to address specific needs. d. Suggest respite care breaks for parents during the week. e. Consider making small changes rather than large changes.
b. Try to think of alternative responses to the child's behavior. c. Offer role-playing scenarios to address specific needs. d. Suggest respite care breaks for parents during the week. e. Consider making small changes rather than large changes.
The nurse is working with a group of health care professionals on a program to address the use of substances in the community. Which information would the nurse emphasize to include in the program? a. use of medication b. actions to prevent relapse c. recognizing levels of tolerance d. value of spontaneous remission
b. actions to prevent relapse
The nurse is caring for an adult client that has been admitted to the detoxification unit. Due to acute withdrawal, what cues will the nurse likely assess? a. psychomotor hypoactivity and hypotension b. flushed face, headache, and tremors c. bradycardia and generalized seizures d. anhidrosis, hypotonicity, and delusions
b. flushed face, headache, and tremors
A nurse is working with an adolescent client with a diagnosis of conduct disorder. The nurse is helping the client reflect on a situation in which the client became aggressive and asks how the client could have handled it differently. The nurse is employing which intervention? a. promoting social interaction b. improving coping skills and self-esteem c. increasing treatment compliance d. providing client education
b. improving coping skills and self-esteem
A nurse is talking with the parents of a child with disruptive behavior disorder about ways to help the child manage behaviors. Which action is best for the nurse to advocate for the child to have their needs met? a. support transferring the child to a healthy living environment. b. teach the parents age-appropriate expectations of the child. c. reinforce the parents' expectations of the child's behavior. d. interpret the child's thoughts and feelings to the parent.
b. teach the parents age-appropriate expectations of the child.
The nurse observes a child with ADHD grab another child in a group session. Which response by the nurse is most effective in stopping the behavior? a. "If you can't sit still in the group, you will not be allowed to attend again." b. "It's okay to want to make new friends and show your affection to them." c. "It's not alright to grab other children. When you want something, ask them." d. "I am sure that your parents do not allow you to act this way at home, do they?"
c. "It's not alright to grab other children. When you want something, ask them."
Assessment of an 8-year-old client reveals communication difficulties and an inability to manage age-appropriate tasks. The child undergoes standardized testing. An intelligent quotient (IQ) of which would support a diagnosis of intellectual disability? a. 95 b. 75 c. 65 d. 85
c. 65
A patient arrives to the ED with noticeable thin brittle hair, hypotension, anemia, osteoporosis, and complaints of palpitations, muscle weakness, and constipation. What would you expect the diagnosis for this patient to be? a. Bulimia nervosa b. Binge-eating disorder c. Anorexia nervosa
c. Anorexia nervosa patient can also have lanugo.
The nurse is caring for a client diagnosed with bulimia. Which would be important for the nurse to do first? a. Identify the cues related to binging. b. Control the eating responses. c. Ask the client directly about thoughts of suicide or self-harm. d. Provide small regular meals and snacks.
c. Ask the client directly about thoughts of suicide or self-harm.
When assessing a client, you note that the client withdraws into themselves and into a fantasy world of his own creation. What do you suspect this patient's diagnosis to be? a. ADHD b. Conduct Disorder c. Autism d. Separation Anxiety disorder
c. Autism
When a nurse talks to the mother of a 15-year-old client, the mother expresses concern over the client's eating and exercise habits. The mother says that as soon as the client comes home from school, the client exercises for 2 to 3 hours every day. She says the client eats very little at dinner, but in the morning she notices that large amounts of food are missing from the kitchen. The client was complaining of tooth pain, and when the mother took the client to the dentist, the client had over 10 cavities. Which disorder is the client most likely suffering from? a. Anorexia nervosa b. Binge-eating disorder c. Bulimia nervosa d. Eating disorder not otherwise specified
c. Bulimia nervosa
An infant being evaluated is noted to have a small head size, shorter-than-average height, and low body weight. What would you suspect the diagnosis to be? a. Autism b. ADHD c. Fetal Alcohol Syndrome d. Conduct
c. Fetal Alcohol Syndrome
A client has been diagnosed with anorexia nervosa. To assist the client to cope with her disease process, the client will complete which of the following actions? a. Drinking 4 L of fluid per day. b. Pacing around the unit most of the day. c. Keeping a journal and discussing it with the nurse. d. Talking almost constantly with friends by telephone.
c. Keeping a journal and discussing it with the nurse.
While working in your clinic you notice a patient diagnosed with Autism rocking back and forth in their chair while also "hand flapping". What should be your first priority action? a. Tell the patient to stop. b. Call the doctor immediately. c. No intervention needed. d. Administer medications ASAP.
c. No intervention needed. You only stop behaviors if it is harming the patient or others. This behavior is relieving their anxiety.
As nurse observes a preschool-aged child refusing the efforts of the parents to provide comfort during a physical examination. The preschool-aged child displays aggressive behavior and begins to hit and flail. The parents just turn their back on the child, which only serves to make things worse. Based on this presentation, what is the best nursing response? a. Assess for child abuse. b. Refer the family and child for counseling. c. Provide a safe environment. d. Ask the child to explain their behavior.
c. Provide a safe environment.
The immediate goal of nursing interventions in the care of a client with anorexia nervosa is which of the following? a. Changing her irrational thinking about her body. b. Establishing a target weight to be achieved by discharge. c. Restoring nutritional status to normal. d. Gaining insight into the effects of anorexia on her physical health.
c. Restoring nutritional status to normal.
After complaining of weakness and confusion while at school, a 16-year-old client was admitted to the hospital where admission assessments revealed hypokalemia. The client has normal body weight. In planning the client's nursing care and treatment, which outcome should be prioritized? a. The client will verbalize fears relating to the client's health needs. b. The client will acknowledge self-harm thoughts. c. The client will be free of self-induced vomiting. d. The client will identify alternatives to current coping patterns.
c. The client will be free of self-induced vomiting.
While interviewing a child, the nurse notes phonic tics. Which of the following might the nurse assess? Select all that apply. a. Jerking of the shoulders. b. Facial grimacing. c. Throat clearing. d. Grunting. e. Voicing of obscenities.
c. Throat clearing. d. Grunting. e. Voicing of obscenities.
A client diagnosed with anorexia nervosa weighs 78% of their ideal body weight and continues to state that they are "fat". Which symptom does the nurse identify? a. negative self-concept b. low self-esteem c. body image distortion d. drive for thinness
c. body image distortion
A preadolescent client has been considered a neighborhood bully for several years. Peers avoid them, and the parent says, "I cannot believe a thing my child tells me." Recently, the client was observed shooting at several dogs with a pellet gun and setting fire to a vacant lot for the first time. A nurse would assess these behaviors as being most consistent with which disorder? a. pyromania b. oppositional defiant disorder c. conduct disorder d. defiance of authority
c. conduct disorder
After being arrested for prostitution, an adolescent client has been referred to a mental health clinic by a juvenile officer. The client has a history of truancy and being physically abusive to siblings. From the history gathered during assessment, the nurse identifies that these behaviors correlate with which disorder? a. intermittent explosive disorder b. oppositional disorder c. conduct disorder d. childhood depressive disorder
c. conduct disorder
Brain images of people with ADHD have suggested decreased metabolism in which of the following cerebral lobes? a. parietal b. occipital c. frontal d. temporal
c. frontal
A patient is being observed in the psychiatric unit, upon assessment you determine that the patient is able to perform social skills and capable of independent living with assistance, and their IQ is 60. What level of IDD would you suspect this patient to be diagnosed with? a. moderate b. profound c. mild d. severe
c. mild IQ 50 - 70.1 Capable of developing social skills and independent living, with assistance.
An adolescent client is brought for emergency care after being found stuporous from sniffing glue. Which treatment will the nurse anticipate for the client? a. naloxone b. antiemetic c. oxygen therapy d. temporary pacemaker
c. oxygen therapy
A patient with severe IDD is being assessed in your clinic, what would you determine to be the nurses first priority diagnosis? a. anxiety b. ineffective coping c. risk for injury d. defensive coping
c. risk for injury risk for injury & self-care deficit are the top two nursing diagnoses.
An adolescent patient requiring complete supervision is trained in elementary hygiene skills and has an IQ of 28. What is the suspected IDD level for this patient? a. mild b. moderate c. severe d. profound
c. severe IQ 20 - 34
The nurse provides care for a client who is diagnosed with anorexia nervosa. Which question should the nurse ask to assess the client for neuropsychiatric complications associated with the diagnosed eating disorder? a. "How often do you menstruate?" b. "Is your skin dry and your nails brittle?" c. "Do you experience constipation or diarrhea?" d. "Do you experience abnormal taste sensations?"
d. "Do you experience abnormal taste sensations?"
The nurse is having a group activity in the day room with adolescent clients with behavioral issues. One of the clients becomes angry and picks up someone else's project and throws it on the floor, breaking it. Which response by the nurse is most appropriate? a. "If you can't behave when we are trying to have an activity, you won't be able to participate." b. "I am so frustrated with you and the way you always have to have your way." c. "Did it make you feel better to hurt your peers' feelings and destroy their hard work?" d. "Throwing things is unacceptable behavior. Tell me why you are upset and let's talk about it."
d. "Throwing things is unacceptable behavior. Tell me why you are upset and let's talk about it."
An outpatient client diagnosed with anxiety, depression, and anorexia nervosa is receiving treatment to develop healthy coping skills. The client has recently lost more weight. Which statement made by the nurse would be appropriate? a. "Who can you reach out to in times of crisis?" b. "Why are you losing more weight?" c. "Are you using the coping skills that you learned in our last session?" d. "What stressors are you currently experiencing?"
d. "What stressors are you currently experiencing?"
The client is brought to the ER with opioid overdose. After the initial assessment for CNS function, what will be the nurse's priority action? a. Monitor condition with frequent vital signs. b. Inquire as to what opioid was taken. c. Focus on cognition and ability to arouse. d. Administer naloxone
d. Administer naloxone
A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen in the ED. The client is oriented but is tremulous, weak, and sweaty and has some GI symptoms. The nurse recognizes these symptoms as typical of which of the following? a. Wernicke-Korsakoff syndrome b. Delirium tremens c. Continuing intoxication d. Alcohol withdrawal syndrome
d. Alcohol withdrawal syndrome
A client meets some (but not all) of the diagnostic criteria for anorexia nervosa. Despite having lost considerable weight, the client's weight is within normal range. The nurse understands that based on DSM-5 criteria, this client would most likely be diagnosed with which of the following? a. Anorexia nervosa b. Bulimia nervosa c. Binge eating disorder d. Eating disorder not otherwise specified
d. Eating disorder not otherwise specified
Which intervention assists the nurse to gain rapport with the child and parent? a. Introduce child and caregiver to staff b. Discuss the history with the caregiver c. Give paperwork to caregiver to complete d. Greet the child in friendly, personal way
d. Greet the child in friendly, personal way
A nurse is developing the plan of care for a client with bulimia. Which intervention would the nurse most likely include? a. Communicating aggressively with the client. b. Encouraging client take time away from peers for a time. c. Nurturing the client's need for dependency. d. Increasing client's coping skills for anxiety.
d. Increasing client's coping skills for anxiety.
After educating a group of students on ADHD, the instructor determines that additional education is required when the group identifies which as a typical characteristic? a. Hyperactivity b. Impulsiveness c. Inattention d. Language difficulty
d. Language difficulty
A mental health nurse is completing an initial assessment on a client diagnosed with anorexia nervosa. Which of the following is a typical characteristic of parents of clients diagnosed with anorexia nervosa? a. A history of substance abuse. b. Maintain an emotional distance from their children. c. Alternate between loving and rejecting their children. d. Overprotect their children.
d. Overprotect their children.
During an initial interview at a clinic, a young female client states that there is nothing wrong with her. Which of the following would indicate to the nurse that this client might have anorexia nervosa? a. Episodes of overeating and excessive weight gain. b. Expressions of a positive self-concept. c. Flexible thought patterns and spontaneity. d. Severe weight loss due to self-imposed dieting
d. Severe weight loss due to self-imposed dieting.
Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder? a. The client has a demonstrated family history of alcoholism. b. The client engages in binge drinking a few times a week rather than drinking consistently each day. c. The client uses marijuana in addition to alcohol. d. The client had six drinks a few hours ago.
d. The client had six drinks a few hours ago.
What is the end-stage of alcoholic liver disease and is believed to be caused by chronic heavy alcohol use? a. leukopenia b. thrombocytopenia c. hepatitis d. cirrhosis
d. cirrhosis
You have a patient with Conduct disorder. When planning the care of this patient, what would you need to ensure is completed as an early intervention? a. group therapy b. isolation c. antipsychotics d. de-escalation
d. de-escalation
The nurse is caring for a client with chronic alcohol use disorder that is experiencing an alteration in memory function. Which laboratory result will the nurse correlate with this assessment finding? a. increased TSH b. decreased iron level c. increased BUN and creatinine d. decreased thiamine level
d. decreased thiamine level
You are evaluating an adolescent patient in your clinic. Upon further assessment you determine that the patient is academically skilled at a second-grade level, with an IQ of 40. What level of IDD would you expect this patient to be diagnosed with? a. mild b. profound c. severe d. moderate
d. moderate IQ 35 - 49
A patient with a history of alcoholism is being admitted to the hospital with withdrawal symptoms. Upon assessing the patient you note hypertension with readings of 190/100 and greater. With this knowledge, what should the nurses' priority concern be? a. bradycardia b. euthyroid c. pruritus d. seizures
d. seizures