Mental Health spring 18 final exam

Methylphenidate

Ritalin, Metadate, Methylin, Concerta, Daytrana(patch) CNS and respiratory stimulation - weak sympathomimetic

Piaget: 2-7 yo

- preoperational stage - ability to think symbolically - thinking is still egocentric - magical thinking

The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

A, B, C, E, F These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

4. Which change in the brains biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-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) REF: Page 484-485 TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

Daniel, an intravenous heroin user, feels intense cravings when he sees hypodermic needles. This might be an example of: A. modeling B. operant conditioning C. classical conditioning D. observational learning

C. classical conditioning

Initial response to stress activates the

Sympathetic Nervous System

The question that would give data of least value to the assessment of family dynamics is A. "What changes have occurred recently at work?" B. "Are your wife and children conforming to your expectations?" C. "Are you experiencing stress associated with conforming to family expectations?" D. "Do you expect others to shun or avoid you because you are seeing a therapist?"

D. The question about others' reaction to seeking help from a psychotherapist will not provide data about family dynamics.

Intellectual Development Disorder

Was mental retardation Deficits in 3 areas: -Intellectual functioning (reasoning, problem solving, planning, judgement, abstract thinking, and academic ability) -Social Functioning (communication and language, interpreting and action on social cues, and regulating emotions) -Practical aspect of daily life (managing age-appropriate activities of daily living, functioning at school or work, and performing self-care Causes: Genetic, problems with pregnancy, environment, or direct result of a medical condition Chromosomal disorders: Fragile X, Down or Klinefelter's syndrome, phenylketonuria

People who regularly take amphetamines to lower their appetite and lose weight, find that, over time: A. they must take more of the drug to get the same effect. B. they are as hungry as ever C. both a and b. D. none of the above.

c. both a and b They must take more of the drug to get the same effect and they are as hungry as ever.

Primary stress hormone

Cortisol

Dextroamphetamine

Dexedrine CNS stimulant: release NEpi from nerve endings

According to the Western scientific view of health, illness is the result of A. pathogens. B. energy blockage. C. spirit invasion. D. soul loss.

A. Disease has a cause (e.g., pathogens, toxins) that creates the effect; disease can be observed and measured.

A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. Which nursing diagnosis has the highest priority? a.Fear b.Risk for injury c.Self-care deficit d.Disturbed thought processes

B A patient experiencing panic-level anxiety is at high risk for injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The patient may have fear, but the risk for injury has a higher priority.

The most powerful form of cannabis is: A. ganja B. hashish C. marijuana D. free-based THC

B. hashish

29. A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B A matter-of-fact approach does not provide the patient 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.

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) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Difference between PTSD and Acute Stress Disorder

Acute Stress Disorder symptoms are the Same as PTSD However, in Acute Stress Disorder, Symptoms resolve in less than 1 month.

What is the goal of Injury and Violence Prevention objective IVP-33? A. Reduce sexual violence B. Reduce physical assaults C. Reduce child maltreatment deaths D. Reduce bullying among adolescents

B. The goal of injury and violence prevention objective IVP-33 is to reduce physical assaults. The goal of IVP-40 is to reduce sexual violence. The objective of IVP-37 is to reduce child maltreatment deaths. The aim of IVP-35 is to reduce bullying among adolescents.

What is the nurse's priority focused assessment for side effects in a child taking methylphenidate (Ritalin) 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

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.

MOst effective treatment for PTSD

Cognitive Behavioral Therapy (CBT)

Nan took the drug she was handed and in a few minutes felt calm and drowsy, and then went to sleep. She probably took: A. heroin B. cocaine C. cannabis D. a barbiturate

D. a barbiturate

What is the most prevalent form of child abuse in the United States?

Neglect

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 541-542 | Page 547-548 TOP: Nursing Process: Evaluation

A nurse is working in a community mental health facility. Which of the following services are appropriate for clients to receive? (Select all that apply.) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Crisis intervention

A. Educational groups B. Medication dispensing programs C. Individual counseling programs

Lisdexamfetamine dimesylate

Vyvanse Blocks NEpi reuptake, increases release of NEpi and DA

A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic 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

d. Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.

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

a. risk for self-harm. Assessments that relate to patient safety take priority. Patients 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.

Julie began by taking on amphetamine a day to control her appetite. After a month or so it did not work as well but two pills did. This is an example of: A. tolerance B. resistance C. withdrawal D. dependence

A. tolerance

5. Because an intervention is required to control a patient's aggressive behavior, a critical incident debriefing takes place. Which topics are the primary focuses of the discussion? Select all that apply. a. Patient behavior associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by staff d. Effect of environmental factors e. Review of theories of aggression

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing the views about the theoretical origins of aggression is less effective.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

20. When assessing a patients plan for suicide, what aspect has priority? a. Patients financial and educational status b. Patients insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patients 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: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A school age child tells the school nurse, "Other kids call me mean names and will not sit with me at lunch. Nobody likes me." Select the nurse's most therapeutic response. a. "Just ignore them and they will leave you alone." b. "You should make friends with other children." c. "Call them names if they do that to you." d. "Tell me more about how you feel."

ANS: D The correct response uses exploring, a therapeutic technique. The distracters give advice, a non-therapeutic technique.

21. Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiologic stability.

ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

Amphetamine mixture

Adderall CNS stimulant: release NEpi from nerve endings

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following in the teaching? (Select all that apply.) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus

B, D

The purpose of an antagonist drug is to: A. stimulate the client to care about becoming drug-free B. block the effect of an addictive drug C. reduce withdrawal effects as one goes off a drug D. provide a placebo effect to replace the drug effect

B. block the effect of an addictive drug

From which of the following symptoms might the nurse identify a chronic cocaine user? A. Clear, constricted pupils B. red, irritated nostrils C. muscle aches D. conjunctival redness

B. red, irritated nostrils

What are external risk factors for substance abuse?

Peer or parental substance use and inclement in legal problems such as truancy or vandalism

Q25. A nurse is admitting a client with a new diagnosis of a personality disorder. Which of the following would make the nurse question this diagnosis? (Select all that apply.) 1. The client has been diagnosed with sickle cell anemia. 2. The client has an inflated self-appraisal and feels a sense of entitlement. 3. The client has a history of a substance use disorder. 4. The client is odd and eccentric but not delusional. 5. The client has an intellectual developmental disorder.

Q25 ANS: 1, 3, 5 Rationale: The DSM-5 states that impairments in personality functioning and the individual's personality trait expression are not better understood as normative for the individual's developmental stage or sociocultural environment. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). The nurse would question the diagnosis of a personality disorder in a client with sickle cell anemia, substance use disorder, or an intellectual developmental disorder.

Q5. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? 1. Being firm, consistent, and empathic, while addressing specific client behaviors 2. Promoting client self-expression by implementing laissez-faire leadership 3. Using authoritative leadership to help clients learn to conform to society norms 4. Overlooking inappropriate behaviors to avoid providing secondary gains

Q5 ANS: 1 Rationale: The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

Q9. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? 1. Altered thought processes R/T increased stress 2. Risk for suicide R/T loneliness 3. Risk for violence: directed toward others R/T paranoid thinking 4. Social isolation R/T inability to relate to others

Q9 ANS: 4 Rationale: An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are not sociable.

Piaget: birth - 2yo

- sensorimotor stage (as observable by learning via putting things in the mouth, manipulating c hands) - accomplishment: object permanence

A nurse is discussing routine follow-up needs for a client who has a new prescription for valproic acid (Depakote). The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium

A

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

A

The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with: a. attention deficit hyperactivity disorder. b. posttraumatic stress disorder. c. communication disorder. d. an anxiety disorder.

A Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with attention deficit hyperactivity disorder. 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.

An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

A Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259 TOP: Nursing Process: Planning

A correctional nurse plans a health education series for prison inmates. Which topic is most important for the nurse to include in this series? a. Sleep hygiene c. Social skills training b. Personal grooming d. Assertive communication

A The most common mental health symptoms experienced by inmates are insomnia and hypersomnia; therefore, sleep hygiene would address these needs. Sleep is a basic physiological need that must be met before higher needs are addressed.

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

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.

Client Needs: Psychosocial Integrity 14. A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, 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?"

A This patient 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 patient'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 patient with her emotional needs. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 326-327 | Page 331-334 TOP: Nursing Process: Implementation

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. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

A, B, D Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder 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 patients 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.

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 some serious medical conditions may be complicated by emotional stress, including: (select all that apply) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

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) REF: Page 326-327 (Table 17-1) TOP: Nursing Process: Implementation

The nurse assesses the wellness beliefs and values of a client from another culture best when asking A. "What do you think is making you ill?" B. "When did you first feel ill?" C. "How can I help you get better?" D. "Did you do something to cause the illness?"

A. Asking the client to suggest reasons for the illness will best provide an opportunity to become familiar with general beliefs and values the client holds regarding his wellness.

One of the features of Alcoholics Anonymous is: A. peer support B. residential services C. alcohol maintenance D. antagonistic

A. peer support

Which is true of pharmacological therapies for treatment of personality disorders? a. Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. b. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. c. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. d. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.

ANS: A

During a one-on-one interaction with the nurse, a patient frequently looks nervously at the door. Select the best comment by the nurse regarding this nonverbal communication. a. "I notice you keep looking toward the door." b. "This is our time together. No one is going to interrupt us." c. "It looks as if you are eager to end our discussion for today." d. "If you are uncomfortable in this room, we can move someplace else."

ANS: A Making observations and encouraging the patient to describe perceptions are useful therapeutic communication techniques for this situation. The other responses are assumptions made by the nurse.

21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is 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) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

18. A depressed patient 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 patient often feels relieved to be able to talk about suicidal ideation. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 | Page 488-490 (Nursing Care Plan 25-1) and (Table 25-3) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

ANS: A Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the patient might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the patient.

38. A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

ANS: A Word salad (schizophasia) is a jumble of words that is meaningless to the listener and perhaps to the speaker as well, because of an extreme level of disorganization.

13. A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

11. Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or anti-anxiety medication.

ANS: A Anger has a strong cognitive component, so using cognition techniques to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

21. The assumption most useful to a nurse planning crisis intervention for any patient is that the patient: a. is experiencing a state of disequilibrium. b. is experiencing a type of mental illness. c. poses a threat of violence to others. d. has a high potential for self-injury.

ANS: A Disequilibrium is the only answer universally true for all patients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. The potential for self-violence or other-directed violence may or may not be a factor in crisis.

9. The staff development coordinator plans to teach the use of physical management techniques when patients become assaultive. Which topic should be emphasized? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors that must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

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 ones 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) REF: Page 481-483 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. The individual should be advised to hide a small suitcase containing a change of clothing for self and for each child. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

Which statement about persons with personality disorders is accurate? a. they, unlike those with mood or psychotic disorders, are at very low risk of suicide b. they tend not to perceive themselves as having a problem but instead believe their problems are caused by how others behave toward them c. they are believed to be purely psychological disorders, that is, disorders arising from psychological rather than neurological or other other physiological abnormalities d. their symptoms are not as disabling as most other mental disorders, therefore their care tends to be less challenging and complicated for staff

ANS: B

6. A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. suicide potential. c. mood disturbance. d. level of anxiety.

ANS: B 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) REF: Page 486-487 (Table 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

As a patient diagnosed with a mental illness is being discharged from a facility, a nurse invites the patient to the annual staff picnic. What is the best analysis of this scenario? a. The invitation facilitates dependency on the nurse. b. The nurse's action blurs the boundaries of the therapeutic relationship. c. The invitation is therapeutic for the patient's diversional activity deficit. d. The nurse's action assists the patient's integration into community living.

ANS: B The invitation creates a social relationship rather than a therapeutic relationship.

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: 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. (The educator may reformat this question as multiple response.)

27. Which health care worker should be referred to critical incident stress debriefing? a. Nurse who works at an oncology clinic where patients receive chemotherapy b. Case manager whose patients are seriously mentally ill and are being cared for at home c. Health care employee who worked 8 hours at the information desk of an intensive care unit d. Emergency medical technician (EMT) who treated victims of a car bombing at a department store

ANS: D Although each of the individuals mentioned experiences job-related stress on a daily basis, the person most in need of critical incident stress debriefing is the EMT, who experienced an adventitious crisis event by responding to a bombing and provided care to victims of trauma.

2. A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: D Anxiety is the result of a personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Weak" is not a level of anxiety. Mild and moderate levels of anxiety allow the patient to function at a higher level.

24. A troubled adolescent opened fire in a high school cafeteria, fatally shooting three people and injuring many others. Hundreds of parents come to the high school after hearing the news reports. After the police arrest the shooter, which action should occur next? a. Ask the police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet, and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

ANS: D Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet helps anxious parents and their children to unite. Preventing parents from uniting with their children would further incite the situation.

21. A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: 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 patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive. REF: Page 460-461 | Page 463 (Table 24 - 2)

21. Information from a patient's record that indicates marginal coping skills and the need for careful assessment of the risk for violence is a history of: a. childhood trauma. b. family involvement. c. academic problems. d. chemical dependence.

ANS: D The nurse should suspect marginal coping skills in a patient with chemical dependence. He or she is often anxious, may be concerned about inadequate pain relief, and may have a personality style that externalizes blame. The incorrect options do not signal as high a degree of risk as chemical dependence.

4. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: D The patient's statements reflect the use of the ego defense mechanism denial. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.

17. Which scenario is an example of an adventitious crisis? a. Death of a child from sudden infant death syndrome b. Being fired from a job because of company downsizing c. Retirement of a 55-year-old d. Riot at a rock concert

ANS: D The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of situational or maturational crises.

Which assessment question would produce data that would help a nurse understand healing options acceptable to a client of a different culture? A. "Is there someone in your community who usually cures your illness?" B. "What usually helps people who have the same type of illness you have?" C. "What questions would you like to ask about your condition?" D. "What sorts of stress are you presently experiencing?"

B. Asking about typical treatment seeks information about the "usual" cultural treatment of the disorder experienced by the client.

Jeremy took a pill to help cure his alcoholism. He later drank a glass of wine and felt very nauseous. The drug was a(n) ______ drug, such as ______. A. antianxiety; benzodiazepine B. antagonist; disulfiram C. partial antagonist; naltrexone D. detoxification; buspar

B. antagonist; disulfiram

The chief danger of LSD use is: A. the risk of developing drug tolerance B. the possibility of very powerful, sometimes negative reactions C. the severity of withdrawal symptoms among even occasional users D. the universal occurrence of "flashbacks" among former users

B. the possibility of very powerful, sometimes negative reactions

Which factor presents the highest risk for a child to develop a psychiatric disorder? a. Having an uncle with schizophrenia c. Living with an alcoholic parent b. Being the oldest child in a family d. Being an only child

C Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Being in a middle-income family and being the oldest child do not represent psychosocial adversity. Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family offers a greater risk.

Which treatment setting would necessitate the most restrictive care environment? a. Partial hospitalization program c. Forensic hospital b. Geropsychiatric unit d. Group home

C Patients in forensic hospitals have mental illness as well as conviction or charges for criminal activity. These settings must be therapeutic but also confine patients from society. Rules, regulations, and restrictions have similarities to prisons.

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 c. Social skills group b. Simple restitution d. Insight-oriented group therapy

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.

When a 5-year-old is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: 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.

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.

A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first? A. A client who recently burned her arm while using a hot iron at home. B. A client who requests that her antipsychotic medication be changed due to some new side effects. C. A client who says he is hearing a voice that tells him he is not worthy of living anymore. D. A client who tells the nurse he experienced symptoms of severe anxiety before and during a job interview.

C. A client who says he is hearing a voice that tells him he is not worthy of living anymore.

A client, diagnosed with chronic alcoholism, says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? A. Carbamazepine (Tegretol) B. Clonidine (Catapres) C. Disulfiram (Antabuse) D. Folic acid (Folvite)

C. Disulfiram (Antabuse) Disulfiram is used as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high. It is important that the client understands that all alcohol, oral, and topical, and medications that contain alcohol, are strictly prohibited when taking this drug.

A nurse is working on promotion of healthy coping skills with older adult clients who had all previously been hospitalized for severe depression and are now in a residential care facility. The nurse should recognize that this an example of which of the following? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Mental status examination

C. Tertiary prevention

Drinking alcohol during pregnancy can damage the developing embryo and fetus, resulting in: A. excessively large babies B. Sudden Infant Death Syndrome C. fetal alcohol syndrome D. all of the above

C. fetal alcohol syndrome

The psychiatric forensic nurse provides this description of work responsibilities: "I use knowledge of psychopathology as I investigate and reconstruct crimes and then try to understand a criminal's reasoning process. This allows me to compile information on what type of individual would have most likely committed the crime." The work the nurse describes is that of a: a. competency therapist. c. forensic examiner. b. hostage negotiator. d. criminal profiler

D Criminal profilers attempt to provide law enforcement with specific information and the type of individual who would have committed a certain crime. Profilers use behavioral and psychological indicators left at violent crime scenes and apply their understanding of psychopathology, attempt to reconstruct the crime, formulate hypotheses, and develop a profile, which is then tested against known data. The distracters refer to roles the psychiatric forensic nurse may fill, but none of these roles fits the description given in the scenario.

A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice b. Orange juice c. Hot tea d. Milk

D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 264 (Table 14-5) TOP: Nursing Process: Implementation

Which nursing intervention relates to rehabilitative care or a recovering alcoholic? A. Providing a safe and supportive environment during alcohol withdrawal B. teaching about physical symptoms C. Providing client and family education and assistance during treatment D. encouraging continued participation in AA

D. encouraging continued participation in AA Encouraging continued participation in AA is a nursing intervention during rehabilitative care. Because recovery is a long-term process, it is critical that the nurse encourage continuous participation in outpatient support systems such as AA.

What's the definition of pyromania?

Deliberate fire setting on >1 occasion + fascination and gratification with fire setting and related behaviors

T/F: Patients with kleptomania feel no guilt or remorse after stealing an object

False! They have intense guilt

Why are children harder to diagnose?

Limited language skills and cognitive and emotional development

Q 12. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? 1. "You really don't have to go by that schedule. I'd just stay home sick." 2. "There has got to be a hidden agenda behind this schedule change." 3. "Who do you think you are? I expect to interact with the same nurse every Saturday." 4. "You can't make these kinds of changes! Isn't there a rule that governs this decision?"

Q 12ANS: 4 Rationale: The nurse should identify that a client with obsessive-compulsive personality disorder would have a difficult time accepting changes. This disorder is characterized by inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

Atomoxetine

Strattera

It is important for nurses to take what kind of perspective?

Strength-based (eg focus on what client can do, not what they can't)

Which assessment finding best supports dissociative fugue? The patient states: 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."

a. "I cannot recall why I'm living in this town." The patient 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. See relationship to audience response question.

A patient 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 patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

b. Engage the patient in a physical activity such as exercise. Helping the patient apply a grounding technique, such as exercise, assists the patient 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 patient. It is not necessary to notify the health care provider.

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic 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

b. Flashback 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.

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 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."

d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse. Confrontation will not be effective. While its important to provide information, on-going support will be more effective.

A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

d. Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on-going.

A nurse assesses an individual who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder? a."I check where my car keys are eight times." b."My legs often feel weak and spastic." c."I'm embarrassed to go out in public." d."I keep reliving a car accident."

A Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but fails and must be repeated. Stating "My legs feel weak most of the time" is more in keeping with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant personality disorder. Reliving a traumatic event is associated with posttraumatic stress disorder. See relationship to audience response question.

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

A Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with attention deficit hyperactivity disorder. The other medication categories listed would not be appropriate.

29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

ANS: A A neologism is a newly coined word having special meaning to the patient. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

Which statement shows a nurse has empathy for a patient who made a suicide attempt? a. "You must have been very upset when you tried to hurt yourself." b. "It makes me sad to see you going through such a difficult experience." c. "If you tell me what is troubling you, I can help you solve your problems." d. "Suicide is a drastic solution to a problem that may not be such a serious matter."

ANS: A Empathy permits the nurse to see an event from the patient's perspective, understand the patient's feelings, and communicate this to the patient. The incorrect responses are nurse- centered (focusing on the nurse's feelings rather than the patient's), belittling, and sympathetic.

Select all that apply. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: a. avoids people and places that arouse painful memories. b. experiences flashbacks or reexperiences the trauma. c. experiences symptoms suggestive of a heart attack. 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 posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

Termination of a therapeutic nurse-patient relationship has been successful when the nurse: a. avoids upsetting the patient by shifting focus to other patients before the discharge. b. gives the patient a personal telephone number and permission to call after discharge. c. discusses with the patient changes that happened during the relationship and evaluates outcomes. d. offers to meet the patient for coffee and conversation three times a week after discharge.

ANS: C Summarizing and evaluating progress help validate the experience for the patient and the nurse and facilitate closure. Termination must be discussed; avoiding discussion by spending little time with the patient promotes feelings of abandonment. Successful termination requires that the relationship be brought to closure without the possibility of dependency-producing ongoing contact.

7. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What type of crisis is this person experiencing? a. Maturational b. Adventitious c. Situational d. Recurring

ANS: C A situational crisis arises from an external source and involves a loss of self-concept or self-esteem. An adventitious crisis is a crisis of disaster, such as a natural disaster or crime of violence. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists.

22. Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia? a."I'm sure I will get over not wanting to leave home soon. It takes time." b."Being afraid to go out seems ridiculous, but I can't go out the door." c."My family says they like it now that I stay home most of the time." d."When I have a good incentive to go out, I can do it."

B Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. The symptom is ego dystonic. However, patients will state they are unable to change the behavior. Agoraphobics are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone (BuSpar) b. lorazepam (Ativan) c. amitriptyline (Elavil) d. desipramine (Norpramin)

B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

A patient experiencing moderate anxiety says, "I feel undone." An appropriate response for the nurse would be: a."What would you like me to do to help you?" b."Why do you suppose you are feeling anxious?" c."I'm not sure I understand. Give me an example." d."You must get your feelings under control before we can continue."

C Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying helps the patient identify thoughts and feelings. Asking the patient why he or she feels anxious is non-therapeutic; the patient likely does not have an answer. The patient may be unable to determine what he or she would like the nurse to do in order to help. Telling the patient to get his or her feelings under control is a directive the patient is probably unable to accomplish.

A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action. a.Ask, "I'm not sure what you mean. Give me an example." b.Capture the patient in a basket-hold to increase feelings of control. c.Tell the patient, "Stop running and take a deep breath. I will help you." d.Assemble several staff members and say, "We will take you to seclusion to help you regain control."

C Safety needs of the patient and other patients are a priority. Comments to the patient should be simple, neutral, and give direction to help the patient regain control. Running after the patient will increase the patient's anxiety. More than one staff member may be needed to provide physical limits, but using seclusion or physically restraining the patient prematurely is unjustified. Asking the patient to give an example would be futile; a patient in panic processes information poorly.

A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety? a. Mild b. Moderate c. Severe d. Panic

C The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment. Somatic symptoms such as those described are usually present. The individual with mild anxiety is only mildly uncomfortable and may even find his or her performance enhanced. The individual with moderate anxiety grasps less information about a situation and has some difficulty with problem solving. The individual in panic will demonstrate markedly disturbed behavior and may lose touch with reality.

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

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.

A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a."Have you been a victim of a crime or seen someone badly injured or killed?" b."Do you feel especially uncomfortable in social situations involving people?" c."Do you repeatedly do certain things over and over again?" d."Do you find it difficult to control your worrying?"

D Patients with generalized anxiety disorder frequently engage in excessive worrying. They are less likely to engage in ritualistic behavior, fear social situations, or have been involved in a highly traumatic event.

A person who has been unable to leave home for more than a week because of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? a.Help the person use online video calls to provide interaction with others. b.Advise the person to accept the situation and use a companion. c.Ask the person to explain why the fear is so disabling. d.Teach the person to use positive self-talk techniques.

D Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety." This technique helps the patient gain mastery over the symptoms. The other options reinforce the sick role.

An individual who is addicted to heroin is likely to experience which of the following symptoms of withdrawal? A. increased heart rate and BP B. tremors, insomnia, and seizures C. incoordination and unsteady gait D. N/V, diarrhea and diaphoresis

D. N/V, diarrhea and diaphoresis

A patient in the emergency department reports, "My boyfriend forced me to have sex with him but I did not want to. I told him 'no' but he would not listen." Which nurse is best prepared to assist this patient? A. Forensic nurse generalist B. Forensic psychiatric nurse C. Advanced practice forensic nurse D. Sexual assault nurse examiner (SANE)

D. The SANE is a forensice nurse generalist who has training in the care of adult and pediatric victims of sexual assault. This patient may or may not decide to pursue criminal charges against the boyfriend. A SANE can perform an exam and counsel the patient regarding the decision. The forensic nurse generalist, forensic psychiatric nurse, and advanced practice forensic nurse are not credentialed to perform an exam of the patient.

Dexmethylphenidate

Focalin CNS and respiratory stimulation - weak sympathomimetic

Response of the body to stress

Increased mental activity, Dilated Pupils, Bronchiolar dilation, increased respiratory rate, increased heart rate, increased glucose, increased cardiac output, increased fatty acids, increased arterial blood pressure, increased blood flow to skeletal muscles

What impulse disorder results in an violent act that's out of proportion to the initial stressor, followed by the pt being calm, relaxed, and showing no remorse?

Intermittent Explosive Disorder

Piaget: 11+ yo

- formal operational - thinking abstractly, working things out in one's head that have not actually been seen in real world - relativistic, shades of grey - algebra becomes possible - not everyone gets here, per Piaget

Disinhibited Social Engagement Disorder

-A pattern of behavior in which a child actively approaches & interacts w/ unfamiliar adults: reduced reticence, overly familiar behavior, diminished checking back, willingness to go off w/ an unfamiliar adult -Experienced a pattern of extremes of insufficient care (cause)

Characteristics of a mentally healthy child or adolescent:

-Trusts others and sees world as being safe -Correctly interprets reality -Behaves in a developmentally appropriate way and does not violate social norms, -Positive, realistic self concept -Adapts to and copes with anxiety and stress -Learn and master developmental tasks -Expresses self -Maintains satisfying relationships

What are the diagnostic criteria for intermittent explosive disorder?

1. Twice a week in 3 months without harm OR 2. 3 times a year with harm

Q15. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? 1. The client experiences unwanted, intrusive, and persistent thoughts. 2. The client experiences unwanted, repetitive behavior patterns. 3. The client experiences inflexibility and lack of spontaneity when dealing with others. 4. The client experiences obsessive thoughts that are externally imposed.

15 ANS: 3 Rationale: The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals with this disorder are very serious, formal, and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

The ED nurse assesses a confused client diagnosed with alcohol use disorder and notes the use of confabulation. Which complication of alcohol use disorder would the nurse suspect? A. Korsakoff's psychosis B. Vascular neurocognitive disorder C. Wernicke's encephalopathy D. esophageal varices

A. Korsakoff's psychosis The symptoms described are those associated with Korsakoff's psychosis. Korsakoff's psychosis is identified by a syndrome of confusion, loss of memory, and confabulation. Confabulation is the creating of imaginary events to fill in memory gaps.

30. Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will: a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

14. A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select 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 patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient 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. REF: Page 465-466

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Parietal lobe

ANS: A, D The amygdala mediates anger experiences and helps a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The cerebellum manages equilibrium, muscle tone, and movement. The basal ganglia are involved in movement. The parietal lobe is involved in interpreting sensations.

A nurse introduces the matter of a contract during the first session with a new patient because contracts: a. specify what the nurse will do for the patient. b. spell out the participation and responsibilities of each party. c. indicate the feeling tone established between the participants. d. are binding and prevent either party from prematurely ending the relationship.

ANS: B A contract emphasizes that the nurse works with the patient rather than doing something for the patient. "Working with" is a process that suggests each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, and premature termination is forbidden.

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

ANS: B Ideas of reference are misinterpretations of the verbalizations or actions of others that give special personal meanings to these behaviors; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient 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. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: 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. See relationship to audience response question.

12. Which assessment finding presents the greatest risk for violent behavior? A patient who: a. is severely agoraphobic. b. has a history of spousal abuse. c. demonstrates bizarre somatic delusions. d. verbalizes hopelessness and powerlessness.

ANS: B A history of prior aggression or violence is the best predictor of patients who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have co-existing anger, but violence is not often demonstrated. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

7. An intramuscular dose of antipsychotic medication needs to be given to a patient who is becoming increasingly more aggressive. The patient is in the day room. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your doctor prescribed for you?" b. accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you feel more comfortable." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male nursing assistant and tell the patient, "You can come to your room willingly so I can give you this medication, or the aide and I will take you there."

ANS: B A patient gains feelings of security if he or she sees that others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes that the patient can act responsibly and will maintain control. Physical control measures should be used only as a last resort.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

20. An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

ANS: B The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. 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 patients with personality disorders; each might apply to selected clinical diagnoses, but not to others. REF: Page 458 | Page 467 (Table 24-3)

1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, C, F The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

3. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: 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.

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: Apply (Application) REF: Page 487-490 (Table 25-3) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity

22. A patient with pneumonia has been hospitalized for 4 days. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking, leading to cognitive distortion. c. personality style that externalizes problems. d. delusions that others wish to deliver harm

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to soothe themselves. The incorrect options are less likely to have a bearing on this behavior.

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 Patients 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. REF: Page 461-463 (Table 24 - 2)

15. A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by: a. gently touching the patient's arm. b. asking the patient, "What do you need?" c. saying to the patient, "This is a safe place." d. directing the patient to cease the behavior.

ANS: C Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient's attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient's attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.

11. A patient visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is _____________ weeks. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 6 to 12

ANS: C The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If the crisis is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

8. A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient 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 patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

9. The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

A nurse in a primary care clinic is collecting data from a client who takes lithium carbonate (Lithobid) for the treatment of bipolar disorder. The nurse should recognize which of the following findings as a possible indication of toxicity from this medication? A. Severe hypertension B. Coarse tremmors C. Constipation D. Urinary retention

B. Coarse tremmors

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). 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

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.

Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

C The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 250-251 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259 TOP: Nursing Process: Diagnosis/Analysis

The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C, D, E Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 257 | Page 261 TOP: Nursing Process: Planning

A client diagnosed with chronic alcohol use disorder complains of feeling tremulous. The client's BP is now 170/110, P 116, R 30, T 97F. The nurse anticipates which medication would give the client the most immediate relief from these symptoms? A. Benztropine (Cogentin), 2 mg PO B. Oxazepam (Serax), 30 mg PO C. Lorazepam (Ativan), 1 mg IM D. Meperidine (Demerol), 100 mg IM

C. Lorazepam (Ativan), 1 mg IM Ativan is frequently used to treat the symptoms of alcohol withdrawal. Because Ativan is ordered parenterally, this medication would give the client the most immediate relief of symptoms

When teaching a client diagnosed with alcoholism about nutritional needs, which nutritional concept should the nurse emphasize? A. eat a high-protein, low-carbohydrate diet to promote lean body mass. B. increase sodium-rich foods to increase iodine levels C. Provide multivitamin supplements, including thiamine and folic acid. D. Restrict fluid intake to decrease renal load.

C. Provide multivitamin supplements, including thiamine and folic acid. Vitamin B deficiencies contribute to the nervous system disorders seen in chronic alcohol abuse. Supplements of these vitamins are important to prevent complications. It is important that vitamin supplements include both thiamine (vitamin B1) and folic acid.

Dan has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job. Dan's drinking buddies come for a visit, and when they leave, the nurse smells alcohol on Dan's breath. Which of the following would be the best intervention with Dan at this time? A. Search his room for evidence B. Ask, "Have you been drinking alcohol, Dan?" C. Send a urine specimen from Dan to the lab for drug screening D. Tell Dan, "These guys cannot come to the unit to visit you again."

C. Send a urine specimen from Dan to the lab for drug screening

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following is appropriate when implementing this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator. C. Gradually expose the client to an elevator while practicing relaxation techniques. D. Stay with the client in an elevator until his anxiety response diminishes. ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

C: A=modeling B=thought stopping D=flooding ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

Research indicates that the most important neurotransmitter in the "pleasure pathway" of the rain is probably: A. acetylcholine B. anandamide C. endorphins D. dopamine

D. dopamine

A client is brought to the ED. The client is aggressive, has slurred speech, and impaired motor coordination. Blood alcohol level is 347 mg/dl. Among the physician's orders is thiamine. Which is the rationale for this intervention? A. to prevent nutritional deficits B. to prevent pancreatitis C. to prevent alcoholic hepatitis D. to prevent Wernicke's encephalopathy

D. to prevent Wernicke's encephalopathy Wernicke's encephalopathy is the most serious form of thiamine deficiency in clients diagnosed with alcoholism. if thiamine replacement therapy is not undertaken quickly, death will ensue.

What are two main problems for vulnerable populations?

Lack of services and premature termination of treatment

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

NS: D Taking an antipsychotic medication coupled with the presence of extrapyramidal symptoms, such as severe muscle stiffness and difficulty swallowing, hyperpyrexia, and autonomic symptoms (pulse elevation), suggest neuroleptic malignant syndrome, a medical emergency. The symptoms given in the scenario are not consistent with the medical problems listed in the incorrect options.

Childhood protective factors:

Self-control, parental monitoring, academic achievement, anti-drug use policies, and strong neighborhood attachment

Familial risk factors that correlate with child psychiatric disorders:

Severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care

What's the difference b/w theft and kleptomania?

Theft: Desire for object and able to resist, object has value and pt can't afford. Planned. Object is used or kept w/o remorse or guilt Kleptomania: lowers anxiety and unable to resist. Object has no value, pt can afford it. Unplanned, without help. Often object is stashed, gifted, or returned. Remorse and guilt are present

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." Select 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.

a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." 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.

Characteristics of the resilient child:

- adaptability to changes in the environment - ability to form nurturing relationships with other adults when the parent is not available - ability to distance self from emotional abuse - good social intelligence - good problem-solving skills - ability to perceive a long-term future

Piaget: 7-11 yo

- concrete operational - beginning of logical/operational thought replacing intuition - but still tied to reality, still need hands-on (drawing, object manipulation, concrete examples) - conservation is achieved (https://www.simplypsychology.org/conservation2.jpg)

Guiding Principles of Play Therapy:

-Accept children as they are and follow their lead -Establish a warm, friendly relationship that fosters the expression of feelings completely -Recognize the child's feelings and reflect them back to promote insight -Accept the child's ability to solve personal problems -Set limits only to provide reality and security

Autism Spectrum Disorder

-Appear within the child's first 3 years of life -Affects the normal development of the brain in social interaction and communication skills -Stereotypical repetitive speech, use of objects, over adherence to routines or rituals, fixations with particular objects, hyper- or hypo-reactivity to sensory input, and extreme resistance to change -Fragile X, tuberous sclerosis, and Rett Syndrome -4 times more common in boys -Only about 1/3 achieve partial independence -Problems with left hemispheric functions -First noticed when the infant fails to be interested in others or to be socially responsive though eye contact and facial expressions -Puberty can be turning point for deterioration or improvement -Risperidone, Olanzapine, Quietiapine, Aripiprazole -SSRIs are the most popular -Ultimate goal is to create an informed, activated patient and family with adequate support for decision make and self-management

What dramatic changes occur in the brain during childhood and adolescence?

-Declining number of synapses (Peaks at 5) -Myelination of brain fibers -Changes in the relative volume and activity level in different brain regions -Interactions of hormones

Adjustment Disorder

-Emotional or behavioral symptoms developed in response to an identifiable stressors -These symptoms or behaviors are clinically significant -Symptoms do not represent normal bereavement -Short-term diagnosis: not over 6 mths

Acute Stress Disorder

-Exposure to actual or threatened death, serious injury, or sexual violation -Presence of symptoms of intrusion, negative mood, dissociation, avoidance, & arousal, beg. or worse. after events -Duration of 3 days to 1 mth after trauma -Causes clinically significant distress or impairment in functioning -10% to 20% of children

ADHD

-Inappropriate degree of inattention, impulsiveness, and hyperactivity -Symptoms must be present in at least 2 settings and occur before the age of 12 -Adults have to have fewer symptoms -Most often diagnosed when children have difficulty adjusting to elementary school -Low frustration tolerance, temper outbursts, labile moods, poor school performance, peer rejection, and low self-esteem -Boys more than girls -Median age of onset is 7 years old -Aften diagnosed with Oppositional defiant disorder or conduct disorder -Hyperactivity, difficulty taking turns or maintaining social relationships, high level of impulsivity, poor social boundaries, intrusive behaviors, or frequently interrupting others -Correcting the faulty personality -Antipsychotics, lithium, anticonvulsants, and antidepressants -Psychostimulants have a dose-dependant effect -Clonidine -Cognitive behavioral therapy -Methylphenidate and Amphetamine salts are the most widely used -Insomnia is a common side effect and they shouldn't take meds after 4:00 pm Other side effects are appetite suppression, headache, abdominal pain, and lethargy -Strattera is approved for both child and adult; may take 6 weeks; increased incidence of suicidal ideation; most common side effects are GI disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia; may cause liver injury and increased BP and heart rate

Barriers to Assessment in children

-Lack of consensus and clarity about conditions for screening children -Lack of coordination among multiple systems -Lack of community-based resources and long waiting lists for services -Lack of mental health providers -Cost and inadequate reimbursement

Reactive Attachment Disorder

-Pattern of inhibited, emotionally withdrawn behavior toward adult caregivers -Persistent social & emotional disturbance -Experienced a pattern of extremes of insufficient care (cause) -Disturbance evident before 5 years of age

What are the 3 main impulse control problems?

1. Intermittent explosive disorder 2. Pyromania 3. Kleptomania

Q16. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? 1. A client diagnosed with antisocial personality disorder 2. A client diagnosed with borderline personality disorder 3. A client diagnosed with schizoid personality disorder 4. A client diagnosed with paranoid personality disorder

16 ANS: 2 Rationale: The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilating behaviors. Most gestures are designed to elicit a rescue response.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the nurse notes that the lithium blood level is 1.2 mEq/L. Which of the following is an appropriate action by the nurse? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

A

A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following is appropriate to include in the discussion? A. Excessive stressors cause the client to experience distress. B. The body's initial adaptive response to stress is denial. C. The absence of stressors results in homeostasis. D. Negative, rather than positive, stressors produce a biological response.

A

Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a.Altruism b.Suppression c.Intellectualization d.Reaction formation

A Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others. The nurse's reaction is conscious rather than unconscious. There is no evidence of suppression. Intellectualization is a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing. Reaction formation is when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite behavior or emotion.

A patient in the emergency department shows disorganized behavior and incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? a.An interview room furnished with a desk and two chairs b.A small, empty storage room with no windows or furniture c.A room with an examining table, instrument cabinets, desk, and chair d.The nurse's office, furnished with chairs, files, magazines, and bookcases

A Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space in which the patient can move about. A small, empty storage room without windows or furniture would feel like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be over-stimulating and unsafe.

An individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic. Which defense mechanism is evident? a.Rationalization b.Compensation c.Introjection d.Regression

A Rationalization involves unconsciously making excuses for one's behavior, inadequacies, or feelings. Regression involves the unconscious use of a behavior from an earlier stage of emotional development. Compensation involves making up for deficits in one area by excelling in another area. Introjection is an unconscious, intense identification with another person.

A person speaking about a rival for a significant other's affection says in an emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: a.reaction formation. b.repression. c.projection. d.denial.

A Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior. Instead of expressing hatred for the other person, the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea, feeling, or situation to be ignored. Projection involves unconsciously disowning an unacceptable idea, feeling, or behavior by attributing it to another. Repression involves unconsciously placing an idea, feeling, or event out of awareness.

A patient fearfully runs from chair to chair crying, "They're coming! They're coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: a.provide for the patient's safety. b.encourage clarification of feelings. c.respect the patient's personal space. d.offer an outlet for the patient's energy.

A Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient's energy can occur when the current panic level subsides. Respecting the patient's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.

A student says, "Before taking a test, I feel very alert and a little restless." Which nursing intervention is most appropriate to assist the student? a.Explain that the symptoms result from mild anxiety and discuss the helpful aspects. b.Advise the student to discuss this experience with a health care provider. c.Encourage the student to begin antioxidant vitamin supplements. d.Listen attentively, using silence in a therapeutic way.

A Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 12. Which comment by a patient 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."

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) REF: Page 326-327 | Page 331 | Page 334-335 TOP: Nursing Process: Assessment

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 chronic major depression. 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.

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.

Select the best question for a psychiatric forensic nurse examiner to ask when assessing the legal sanity of an individual charged with a crime. a. "Tell me about what you were thinking at the time of the alleged crime." b. "What would you do if you heard a fire alarm going off where you live?" c. "At this time, are you having any experiences that others might think strange?" d. "Do you feel as though you would like to harm yourself or anyone else at the present time?"

A Legal sanity refers to the individual's ability to know right from wrong with reference to the act charged, the capacity to know the nature and quality of the act charged, and the capacity to form the intent to commit the crime. It is determined for the specific time of the act. The distracters apply to other parts of a mental status assessment and do not assess the patient's state at the time of the alleged crime.

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Outcomes Identification

A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 261-263 (Table 14-3) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 13. A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? 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."

A Patients 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) REF: Page 325-326 TOP: Nursing Process: Assessment

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: a. displays resiliency. b. has a passive temperament. c. is at risk for posttraumatic stress disorder. d. uses intellectualization to deal with problems.

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.

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patient's safety. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Physiological 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?"

A Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The patient's dependency needs may be evident through losses of abilities. When secondary gains are prominent, the patient 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) REF: Page 329 | Page 331 TOP: Nursing Process: Assessment

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who: a. have been abused. b. are attention seeking. c. have eating disorders. d. are developmentally delayed.

A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 533 (Box 28-1) TOP: Nursing Process: Assessment

Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

A Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274-275 TOP: Nursing Process: Evaluation

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents b. Deficient knowledge related to interpersonal skills with parents c. Disturbed personal identity related to negative self-evaluation d. Complicated grieving related to poor academic performance

A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 28û22 | Page 23 | Page 51 (Box 28-4) TOP: Nursing Process: Diagnosis/Analysis

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543 | Page 546 TOP: Nursing Process: Implementation

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January b. April c. June d. September

A The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Assessment

An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 537 (Box 28-4) | Page 541-542 TOP: Nursing Process: Diagnosis/Analysis

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Impaired social interaction related to difficulty relating to others 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

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

Client Needs: Safe, Effective Care Environment 2. Which presentations suggest the possibility of a factitious disorder, self-directed 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

A, B Persons with factitious disorders, self-directed 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) REF: Page 337-338 TOP: Nursing Process: Implementation

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? Select all that apply. a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever spank your children?" e. "Calling children 'stupid' injures their self-esteem."

A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 535-537 (Box 28-3) TOP: Nursing Process: Assessment

A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 544-545 | Page 548 (Nursing Care Plan 28-1) TOP: Nursing Process: Planning

A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257 | Page 260-261 (Table 14-2) | Page 264 (Table 14-5) TOP: Nursing Process: Implementation

What statement is true regarding the role of an advanced level forensic psychiatric nurse? Select all that apply. A. Is a member of a multidisciplinary forensic team. B. Is open minded, accepting the point of view of others. C. Has a high degree of mastery of interpersonal communication skills. D. Plays a role in determining the guilt or innocence of a person accused of committing a crime. E. Thrives in environments that are intellectually stimulating while pushing the limits of traditional nursing boundaries.

A, B, C, D The forensic psychiatric nurse is highly skilled in interpersonal communications and able to develop collegial relationships with those in other disciplines. A prerequisite is the ability to listen and accept others' values and motivations in a nonjudgmental fashion. Forensic psychiatric nursing appeals to a particular type of nurse, one who thrives in a stimulating intellectual environment, seeks out opportunities to apply clinical skills to complex legal problems, and enjoys pushing the limits of traditional boundaries. In this capacity, the role of the advanced level forensic psychiatric nurse is not to determine guilt or innocence but to provide assessment data that can help make a final diagnosis within the multidisciplinary forensic team.

A nurse is discussing acute vs. prolonged stress with a client. Which of the following should the nurse identify as an acute stress response? (Select all that apply.) A. Decreased appetite B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

A, B, C, E

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? The nurse should recommend: (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. minimizing opportunities for exercise and play.

A, B, C, E The childs symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the childs 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

A reduction in which violence indicator demonstrates the achievement of a Healthy People 2020 goal? Select all that apply. A. Sexual violence B. Firearm related deaths C. Abductions by strangers D. Child maltreatment deaths E. Bullying among adolescents

A, B, D, E People 2020 goal injury and violence prevention objectives include a reduction in firearm-related deaths, sexual violence, bullying among adolescents, and child maltreatment deaths. A violent crime abduction (kidnapping) by strangers currently is not listed as a goal.

What traits are associated with forensic nurse generalists? Select all that apply. A. Knowledgeable evidence collection in accordance with legal standards B. May serve as a resource in a variety of care providing environments C. Conducts research related to forensic nursing D. Has completed a forensic certificate program E. Possesses excellent assessment skills

A, B, D, E To be called a forensic nurse generalist, the nurse with a baccalaureate or associate degree or diploma may acquire additional knowledge and skills by completing a certificate program that comprises continuing education in an area of forensic nursing. The role of the forensic nurse generalist may vary according to clinical setting, but consistent within this role is the need to be proficient in assessment and treatment of victims of violence, evidence collection and preservation, proper documentation, the legal system, and setting standards of care for victims and perpetrators. A doctor of philosophy (PhD) prepares nurses in an advanced practice role to initiate and conduct research in the area of forensics to ultimately enhance the practice of forensic nursing.

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following are appropriate to include in the plan of care? (SATA) A. Priority restructuring B. Monitoring thoughts C. Diaphramatic breathing D. Journal keeping E. Meditation ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A, B, D: Others are behavioral therapy. Surprise: Journal keeping is a cognitive reframing technique. ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A child was placed in a foster home after being removed from abusive parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? Select all that apply. a.Use a calm manner and low voice. b.Maintain simplicity in the environment. c.Avoid repetition in what is said to the child. d.Minimize opportunities for exercise and play. e.Explain and reinforce reality to avoid distortions.

A, B, E The child has moderate anxiety. A calm manner will calm the child. A simple, structured, predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm, simple explanations that reinforce reality validate the environment. Repetition is often needed when the individual is unable to concentrate because of elevated levels of anxiety. Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical movement helps channel and lower anxiety. Play helps by allowing the child to act out concerns.

Client Needs: Psychosocial Integrity 4. A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient 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 psoriasis at age 12 e. Reports insomnia often results from back pain

A, B, E There is no chronic disease to explain the symptoms for patients with somatic symptom disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological symptoms are common. This disorder is more common in women than in men. Patients with conversion disorder would have a tendency to underrate pain. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 325-326 TOP: Nursing Process: Assessment

A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply. a.Caution in use of machinery b.Foods allowed on a tyramine-free diet c.The importance of caffeine restriction d.Avoidance of alcohol and other sedatives e.Take the medication on an empty stomach

A, C, D Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving or using machinery and the importance of not using other central nervous system depressants such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special diet. Food will reduce gastric irritation from the medication.

. A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257-261 (Table 14-2) | Page 264 (Table 14-5) TOP: Nursing Process: Diagnosis/Analysis

The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? Select all that apply. a.Ineffective home maintenance b.Situational low self-esteem c.Chronic low self-esteem d.Disturbed body image e.Risk for injury

A, C, E Shame regarding the appearance of one's home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.

Nursing students are given a lecture on forensic psychiatric nursing. The instructor asks them to state the roles and functions of an advanced forensic psychiatric nurse. Which response by the students indicates effective learning? Select all that apply. A. Forensic nurse examiner B. Rehabilitation nurse C. Consultant D. Pain management nurse E. Hostage negotiato

A, C, E The roles and functions of the advanced forensic psychiatric nurse involve the role of forensic nurse examiner, which is to collect evidence of the case. The nurse should act as a consultant to the law enforcement agencies and provide information on mental illness of the defendant. The nurse can also help in cross-examining the witness and evaluate his or her behavior. The nurse should act as a hostage negotiator and assess the behavior of the perpetrator before, during, and after imprisonment. The forensic nurse does not act as a rehabilitation nurse; the nurse can refer the patient to the rehabilitation center. The forensic nurse does not act as a pain management nurse but assesses the patient's behavior and recommends a pain management nurse for proper care.

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 543-544 (Box 28-6) TOP: Nursing Process: Planning

A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 265-268 (Box 14-2) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 3. A patient 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 patient? Select all that apply. a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

A, E The patient's verbalization is consistent with spiritual distress. The patient'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) REF: Page 329-333 (Table 17-3) TOP: Nursing Process: Diagnosis/Analysis

Which idea held by the nurse would best promote the provision of culturally competent care? A. Western biomedicine is one of several established healing systems. B. Some individuals will profit from use of both Western and folk healing practices. C. Use of cultural translators will provide valuable information into health-seeking behaviors. D. Need for spiritual healing is a concept that crosses cultural boundaries.

A. A nurse who holds this belief would be likely be open to a variety of established interventions. In truth, nurses cannot apply a standard model of assessment, diagnosis, and intervention to all clients with equal confidence. This leads to culturally irrelevant interventions.

The psychiatric nurse planning and implementing care for culturally diverse clients should understand A. holistic theory. B. systems theory. C. adaptation theory. D. political power theory.

A. In most cultures a holistic perspective prevails, one without separation of mind and body.

In the Eastern tradition, disease is believed to be caused by A. fluctuations in opposing forces. B. outside influences. C. members' disobedience. D. adoption of Western beliefs.

A. In the Eastern tradition, disease is believed to be caused by fluctuations in opposing forces, the yin-yang energies.

Which statement best explains the term "worldview"? A. Beliefs and values held by people of a given culture about what is good, right, and normal. B. Ideas derived from the major health care system of the culture about what causes illness. C. Cultural norms about how, when, and to whom illness symptoms may be displayed. D. Valuing one's beliefs and customs over those of another group.

A. A worldview is a system of thinking about how the world works and how people should behave in the world and toward each other. It is from this view that people develop beliefs, values, and the practices that guide their lives.

A teen says to you, "What's the big deal about using pot? How can it hurt me?" the most accurate reply you could make is: A. "If you're high, you won't be able to remember what you just learned." B. "THC in your body can produce dangerous flashbacks when you get older." C. "even a moderate dose of THC can produce perceptual distortions and coma." D. "you're right - it really own't affect you much in school."

A. "If you're high, you won't be able to remember what you just learned."

A client is being discharged from an alcohol treatment program. The client's wife states, "I'm so afraid that when my husband leaves here, he'll relapse. How can I deal with this?" Which nursing statement would be most appropriate? A. "Many family members of alcoholics find the Al-Anon support group to be helpful." B. "You could try going out and having a few beers with him when he gets the urge to drink." C. "Just make sure he doesn't drink at home. Find all of his hidden bottles and empty them." D. "Tell your husband that if he drinks again, you will leave him."

A. "Many family members of alcoholics find the Al-Anon support group to be helpful." This therapeutic response addresses the wife's concerns by giving information about Al-Anon. Al-Anon is a nonprofit organization that provides group support for the family and close friends of alcoholics.

Paula is attending an education class on addictive disorders. She suspects that her husband may be abusing opiates since he has been taking pills given to him by his brother and she knows the brother had been taking oxycodone for back pain. She asks the nurse how to interpret her husband's behaviors. Which of the following observations by Paula are consistent with opioid intoxication? (Select all that apply). A. "Sometimes he seems euphoric and other times he acts like he doesn't care about anything." B. "Last night he went out without a coat on and it was 15 degrees outside." C. "While we were talking at dinner his speech was rapid and he seemed hyperalert to everything in the environment." D. "He's been having trouble remembering things." E. "Sometimes, it looks like his pupils are very small."

A. "Sometimes he seems euphoric and other times he acts like he doesn't care about anything." B. "Last night he went out without a coat on and it was 15 degrees outside." D. "He's been having trouble remembering things." E. "Sometimes, it looks like his pupils are very small." Feedback 1: One manifestation of opioid intoxication is an initial period of euphoria followed by apathy, which is indicated by her statement that "sometimes he acts like he doesn't care about anything." Feedback 2: Going outside without a coat in subfreezing weather could be inferred as impaired judgment, which is consistent with opioid intoxication. Feedback 4: Impairment in attention and memory is consistent with opioid intoxication. Feedback 5: Paula is describing pupillary constriction, which is consistent with opioid intoxication

A forensic nurse examiner is assigned by the court to evaluate an accused rapist in order to collect medical evidence of a sexual assault. While evaluating the defendant, what appropriate actions does the nurse follow? A. The nurse evaluates the defendant's behavior at the jail and courtroom. B. The nurse remains empathetic and accepting while interacting with the defendant. C. The nurse gives the professional opinion based on the education of the defendant. D. The nurse suggests imprisonment if the defendant has despairing thoughts.

A. A forensic examiner conducts the behavioral evaluation of the defendant or accused with the court order. The nurse should observe the patient's clinical history and behavior at the scene of the incident, jail, and the courtroom. This helps the nurse to effectively evaluate the patient's mental condition. The nurse should not be empathetic and accepting with the defendant. The nurse should be neutral, objective, and detached while evaluating the patient's behavior. This helps to give an effective and unbiased report to the court. Professional opinion can be given by considering scientific principles and advanced education in a specific field. Personal opinion is given by considering upbringing, value system, and education. The nurse should suggest hospitalization and treatment if the defendant has a mental illness. Aggressive behavior and despairing thoughts indicate mental illness.

The initial task of the forensic psychiatric nurse working with a mental ill person accused of committing a crime is to A. Assess the patient's ability to proceed to trial B. Smooth the prisoner's transition from community to prison C. Explain that he or she is as a therapeutic agent rather than a punishment agent D. Orient the person to the concept that health care in prison is a privilege rather than a right

A. Among the responsibilities of the psychiatric forensic nurse, assessment of a patient's competence to proceed to trial is an important responsibility. Smoothing the prisoner's transition from community to prison, explaining that he or she is as a therapeutic agent rather than a punishment agent, and orienting the person to the concept that health care in prison is a privilege rather than a right are options that do not require the intervention of a forensic psychiatric nurse.

Which statement is true regarding incarcerated persons and serious mental illness? A. Incarceration often causes decompensation in those with serious mental illness. B. Those with serious mental illness who are incarcerated see remission of symptoms while in prison. C. Incarceration does not appear to play a role in how a person with serious mental illness functions. D. Incarceration plays a role in that people with serious mental illness receive treatment they may have not had outside of prison.

A. Correctional nurses provide care for many patients with serious mental illness. Because psychiatric facilities for the management of such emergencies are scarce, often these patients end up in jail instead of in a hospital. Once they are in jail, their psychiatric condition often worsens without adequate psychiatric intervention. Incarcerated patients see a remission of symptoms while in prison and incarceration does not appear to play a role in how a person with serious mental illness functions are not correct statements, and incarceration may in fact prevent the inmate from receiving appropriate treatment.

Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job states to the nurse, "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my coworkers." The defense mechanism that Dan is using is A. Denial B. Projection C. Displacement D. Rationalization

A. Denial

Paul, a 65-year old Caucasian, is being seen at the health clinic for hypertension and has a history of alcohol use disorder. Which of the following observations by the nurse are consistent with physical complications associated with chronic alcohol use disorders? (Select all that apply) A. His skin is yellow B. He has a butterfly-shaped rash on his cheeks and nose. C. His abdomen is distended D. He is coughing up blood E. He complains of acute pain in his left eye.

A. His skin is yellow C. His abdomen is distended D. He is coughing up blood Feedback 1: Yellowish skin is evidence of jaundice, which is secondary to cirrhosis of the liver. Cirrhosis of the liver is a common manifestation of end-stage alcoholic liver disease Feedback 3: Abdominal distention can be a manifestation of alcoholic hepatitis, cirrhosis of the liver, and pancreatitis, all of which are complications of alcohol use disorder. Further assessment is warranted. Feedback 4: Coughing up blood may be evidence of several complications of alcoholism, including esophageal varices, which can culminate in potentially fatal hemorrhage. Further assessment is warranted to evaluate for these as well as other potential causes of coughing up blood.

In the DSM-5, the major change in how culture is viewed within each disorder is that: A. Issues related to culture and mental illness are now integrated into the discussion of each disorder rather than separately discussing culture-bound syndromes. B. Issues related to culture and mental illness are markedly absent in the discussion of each disorder C. it is noted that it is impossible for health practitioners to be expected to be culturally aware with the increasing diversity of the United States. D. issues related to culture and mental illness are less important than previously thought in diagnostic criteria.

A. Issues related to culture and mental illness are now integrated into the discussion of each disorder rather than separately discussing culture-bound syndromes.

The nurse is planning care for a patient of the Latin American culture. Which goal is appropriate? a. Patient will visit with spiritual healer once weekly. b. Patient will experience rebalance of yin-yang by discharge. c. Patient will identify sources that increase "cold wind" within 24 hours of admission. d. Patient will contact "singer" to provider healing ritual within 3 days of admission.

A. Patient will identify sources that increase "cold wind" within 24 hours of admission.

Prisoners are the only population group in the United States that has a constitutional right to health care. Why are prisoners granted this right? A. Their civil liberties are taken away from them. B. Their property is taken away by the government. C. They have a higher rate of serious physical illness. D. They have a higher rate of chronic psychiatric illness.

A. Prisoners have most of their civil liberties taken away from them when they are imprisoned. Their movement is strictly restricted. They cannot seek and obtain health care services on their own. Therefore, "adequate" health care is provided to them as a constitutional right. Some of the property of prisoners may be taken away by the government. This however, does not affect their need for health care services. Prisoners do have a higher rate or serious and chronic physical and psychiatric illness compared to others. This increases their need for health care services, but does not suffice as a reason for making health care a constitutional right.

Dan begins attendance at AA meetings. Which of the statements by Dan reflects the purpose of this organization? A. They claim they will help me stay sober. B. I'll dry out in AA, then i can have a social drink now and then. C. AA is only for people who have reached the bottom D. If I lose my job, AA will help me find another.

A. They claim they will help me stay sober.

A nurse is caring for a client who has a new prescription for valproic acid (Depakote). The nurse should instruct the client that while taking this medication he will need which of the following laboratory tests periodically? (Select all that apply) A. thrombocyte count B. Hematocrit C. Amylase D. Liver function tests E. Potassium

A. Thrombocyte count C. Amylase D. Liver function test

Ralph has been a serious drinker for many years. in the past year, the has started having huge memory lapses. He will use made up stories to fill in the gaps. This is a syndrome called: A. confabulation B. Korsakoff's syndrome C. fictional memory D. Wernicke's encephalopathy

A. confabulation

Which issues influence an individual's predisposition to substance-related disorders? (Select all that apply) A. genetic history B. fixation at the oral stage of psychosexual development C. punitive ego D. personality traits E. behavior modeling

A. genetic history B. fixation at the oral stage of psychosexual development D. personality traits E. behavior modeling Feedback 1: Research has indicated that an apparent hereditary factor is involved in the development of substance-use disorders. This is especially evident with alcoholism Feedback 2: theories of psychosexual development state that anxiety in people fixated at the oral stage may be reduced by their consumption of substances such as alcohol. Feedback 4: Certain personality traits, such as low self-esteem, depression and passivity are thought to increase a tendency toward addictive behavior Feedback 5: Studies have shown that children and adolescents are more likely to use substances if they have parents who provide a model for substance abuse.

Which of the following has been implicated in the predisposition to substance abuse? A. hereditary factor B. fixation in the adolescent stage of psychosexual development C. punitive ego D. narcissistic and dependent personality traits

A. hereditary factor

George stopped taking his regular amount of cocaine after using it for months. He will probably experience: A. letdown, depressed feelings, and fatigue B. pain, sweating, mania, and nausea C. excitement, insomnia and hallucinations D. dramatic tremors of the hands and face, rapid heart rate and convulsions

A. let down, depressed feelings, and fatigue

Mr. White is admitted to the hospital after an extended period of binge alcohol drinking. His wife reports that he has been a heavy drinker for a number of years. Lab reports reveal has has a blood alcohol level of 250 mg/dL. He is placed on the chemical addiction unit for detoxification. When would the first signs of alcohol withdrawal symptoms be expected to occur? A. several hours after the last drink B. 2-3 days after the last drink C. 4-5 days after the last drink D. 6-7 days after the last drink

A. several hours after the last drink

A polysubstance abuser makes the statement, "The green and whites do me good after speed." how might the nurse interpret the statement? A. the client abuses amphetamines and anxiolytics B. the client abuses alcohol and cocaine C. the client is psychotic D. the client abuses narcotics and marijuana.

A. the client abuses amphetamines and anxiolytics

A nurse is reviewing laboratory findings and notes that a client's plasma lithium level is 2.1 mEq/L. Which of the following is an appropriate action by the nurse? A. Perform immediate gastric lavage B. Prepare the client for hemodialysis C. Administer an additional oral dose of lithium D. Request a stat repeat of the laboratory test

A.Perform immediate gastric lavage.

A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of his alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol This form of treatment is an example of which of the following? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A: Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior. Flooding: planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response. Biofeedback is a behavioral therapy to control pain, tension, and anxiety. Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior. ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

Which nursing actions demonstrate cultural competence? (SATA) a. Planning meal time around the patient's prayer schedule b. Advising a patient to visit with the hospital chaplain c. Researching foods that a lacto-ovo-vegetarian patient will eat d. Providing time for a patient's spiritual healer to visit e. Ordering standard meal trays to be delivered three times daily

ABCD

A patient says, "Please don't share information about me with the other people." How should the nurse respond? a. "I will not share information with your family or friends without your permission, but I share information about you with other staff." b. "A therapeutic relationship is just between the nurse and the patient. It is up to you to tell others what you want them to know." c. "It depends on what you choose to tell me. I will be glad to disclose at the end of each session what I will report to others." d. "I cannot tell anyone about you. It will be as though I am talking about my own problems, and we can help each other by keeping it between us."

ANS: A A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.

27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

ANS: A A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

ANS: A Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

A community mental health nurse has worked with a patient for 3 years but is moving out of the city and terminates the relationship. When a novice nurse begins work with this patient, what is the starting point for the relationship? a. Begin at the orientation phase. b. Resume the working relationship. c. Initially establish a social relationship. d. Return to the emotional catharsis phase.

ANS: A After termination of a long-term relationship, the patient and new nurse usually have to begin at ground zero, the orientation phase, to build a new relationship. If termination is successfully completed, the orientation phase sometimes progresses quickly to the working phase. Other times, even after successful termination, the orientation phase may be prolonged.

16. Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, 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 patient 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) REF: Page 486-487 TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

A patient says, "I've done a lot of cheating and manipulating in my relationships." Select a nonjudgmental response by the nurse. a. "How do you feel about that?" b. "I am glad that you realize this." c. "That's not a good way to behave." d. "Have you outgrown that type of behavior?"

ANS: A Asking a patient to reflect on feelings about his or her actions does not imply any judgment about those actions, and it encourages the patient to explore feelings and values. The remaining options offer negative judgments.

16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

18. At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: a. codependence. b. assertiveness c. role reversal d. homeostasis.

ANS: A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

ANS: A Concrete thinking refers to an impaired ability to think abstractly. Concreteness is often assessed through the patient's interpretation of proverbs. Concreteness reduces one's ability to understand and address abstract concepts such as love or the passage of time. The incorrect options illustrate echolalia, an unrelated question, and abstract thinking.

18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

ANS: A Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

13. During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

ANS: A During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

While talking with a patient diagnosed with major depression, a nurse notices the patient is unable to maintain eye contact. The patient's chin lowers to the chest, while the patient looks at the floor. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills

ANS: A Eye contact and body movements are considered nonverbal communication. There are insufficient data to determine the level of the patient's social skills or whether a cultural barrier exists.

A patient is having difficulty making a decision. The nurse has mixed feelings about whether to provide advice. Which principle usually applies? Giving advice: a. is rarely helpful. b. fosters independence. c. lifts the burden of personal decision making. d. helps the patient develop feelings of personal adequacy.

ANS: A Giving advice fosters dependence on the nurse and interferes with the patient's right to make personal decisions. It robs patients of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it contributes to patient feelings of personal inadequacy. It also keeps the nurse in control and feeling powerful.

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 patient 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. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

11. A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

ANS: A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjectioninvolves incorporating a quality of another person or group into one's own personality.

A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? a. "The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient." b. "The focus shifts from nurse to patient as the relationship develops. Advice is given by both, and solutions are implemented." c. "The focus of the relationship is socialization. Mutual needs are met, and feelings are shared openly." d. "The focus is creation of a partnership in which each member is concerned with growth and satisfaction of the other."

ANS: A Only the correct response describes elements of a therapeutic relationship. The remaining responses describe events that occur in social or intimate relationships.

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

ANS: A Patients 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 patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse.

Which technique will best communicate to a patient that the nurse is interested in listening? a. Restating a feeling or thought the patient has expressed. b. Asking a direct question, such as "Did you feel angry?" c. Making a judgment about the patient's problem. d. Saying, "I understand what you're saying."

ANS: A Restating allows the patient to validate the nurse's understanding of what has been communicated. Restating is an active listening technique. Judgments should be suspended in a nurse-patient relationship. Close-ended questions such as "Did you feel angry?" ask for specific information rather than showing understanding. When the nurse simply states that he or she understands the patient's words, the patient has no way of measuring the understanding.

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient 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 patient with borderline personality disorder.

13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a. Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b. Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c. Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d. Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

ANS: A Severe constraints on the community mental health nurse's time will probably not allow more time than what is mentioned in the correct option; yet, important principles can be used. A severely withdrawn patient should be met "at the patient's own level," with silence accepted. Short periods of contact are helpful to minimize both the patient's and the nurse's anxiety. Predictability in returning as stated will help build trust. An hour may be too long to sustain a home visit with a withdrawn patient, especially if the nurse persists in leveling a barrage of questions at the patient. Twice-daily visits are probably not possible, and leaving after 10 minutes would be premature. Touch may be threatening. Working on reports suggests the nurse is not interested in the patient.

28. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine - National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

ANS: A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

When a female Mexican American patient and a female nurse sit together, the patient often holds the nurse's hand. The patient also links arms with the nurse when they walk. The nurse is uncomfortable with this behavior. Which analysis is most accurate? a. The patient is accustomed to touch during conversation, as are members of many Hispanic subcultures. b. The patient understands that touch makes the nurse uncomfortable and controls the relationship based on that factor. c. The patient is afraid of being alone. When touching the nurse, the patient is reassured and comforted. d. The patient is trying to manipulate the nurse using nonverbal techniques.

ANS: A The most likely answer is that the patient's behavior is culturally influenced. Hispanic women frequently touch women they consider to be their friends. Although the other options are possible, they are less likely.

As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse's best action? a. Recognize the effectiveness of the relationship and patient's thoughtfulness. Accept the card. b. Inform the patient that accepting gifts violates policies of the facility. Decline the card. c. Acknowledge the patient's transition through the termination phase but decline the card. d. Accept the card and invite the patient to return to participate in other arts and crafts groups.

ANS: A The nurse must consider the meaning, timing, and value of the gift. In this instance, the nurse should accept the patient's expression of gratitude. See relationship to audience response question.

A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's most therapeutic response? a. "You sound very upset about this." b. "God always forgives us for our sins." c. "Why do you think you are being punished?" d. "If you feel this way, you should talk to your minister."

ANS: A The nurse reflects the patient's comment, a therapeutic technique to encourage sharing for perceptions and feelings. The incorrect responses reflect probing, closed-ended comments, and giving advice, all of which are non-therapeutic.

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. The parents reaction reflects: 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) REF: Page 493-494 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

At what point in the nurse-patient relationship should a nurse plan to first address termination? a. During the orientation phase b. At the end of the working phase c. Near the beginning of the termination phase d. When the patient initially brings up the topic

ANS: A The patient has a right to know the conditions of the nurse-patient relationship. If the relationship is to be time-limited, the patient should be informed of the number of sessions. If it is open-ended, the termination date will not be known at the outset, and the patient should know that the issue will be negotiated at a later date. The nurse is responsible for bringing up the topic of termination early in the relationship, usually during the orientation phase.

14. A patient says, "I get in trouble sometimes because I make quick decisions and act on them." Select 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 patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient 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.

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

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient? a. Allowing the patient supervised access to food vending machines b. Allowing the patient to phone a local restaurant to deliver meals c. Offering to taste each portion on the tray for the patient d. Providing tube feedings or total parenteral nutrition

ANS: A The patient who is delusional about food being poisoned is likely to believe restaurant food might still be poisoned and to say that the staff member tasting the food has taken an antidote to the poison before tasting. Attempts to tube feed or give nutrition intravenously are seen as aggressive and usually promote violence. Patients perceive foods in sealed containers, packages, or natural shells as being safer.

17. When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

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) REF: Page 483-484 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

9. What is the priority nursing diagnosis for a patient 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. Patients 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 patients with antisocial personality disorders use denial, they use it effectively.

A nurse says, "I am the only one who truly understands this patient. Other staff members are too critical." The nurse's statement indicates: a. boundary blurring. b. sexual harassment. c. positive regard. d. advocacy.

ANS: A When the role of the nurse and the role of the patient shift, boundary blurring may arise. In this situation the nurse is becoming over-involved with the patient as a probable result of unrecognized countertransference. When boundary issues occur, the need for supervision exists. The situation does not describe sexual harassment. Data are not present to suggest positive regard or advocacy.

22. What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

ANS: A Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that, or any other, medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. Refusing medication is a patient's right and may be appropriate. The other incorrect options do not feature violation of another's rights.

1. Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a patient standing by the pool table. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that or any other medication you try to give me."

ANS: A Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect options do not feature violation of another's rights.

11. Which is an effective nursing intervention to assist an angry patient to learn to manage anger without violence? a. Help the patient identify a thought that increases anger, find proof for or against the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

ANS: A Anger has a strong cognitive component; therefore using cognition to manage anger is logical. The incorrect options do nothing to help the patient learn anger management.

19. An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

ANS: A Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

5. A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion

ANS: A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

9. The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

ANS: A Intervention techniques are learned behaviors and must be practiced to be used in a smooth, organized fashion. Every member of the intervention team should be assigned a specific task to carry out before beginning the intervention. The other options are useless if the staff does not know how to use physical techniques and how to apply them in an organized fashion.

6. A patient was responding to auditory hallucinations earlier in the morning. The patient approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the patient into the day room, the nurse should: a. make sure adequate physical space exists between the nurse and the patient. b. move into a position that allows the patient to be close to the door. c. maintain one arm's length distance from the patient. d. sit down in a chair near the patient.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room is not wise. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

6. A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off" and then goes to the day room. While following the patient into the day room, the nurse should: a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arm's-length distance from the patient. d. begin talking to the patient about appropriate behavior.

ANS: A Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

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 patient 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. Patients with antisocial personality disorders rarely have feelings of fear and inferiority. REF: Page 463 (Table 24-2) | Page 465 | Page 469 (Table 24-4)

6. Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

ANS: A Of the options listed, the priority assessment is the victim's coping mechanisms. The other options have little relevance.

18. An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

ANS: A Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

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

ANS: A Patients 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 patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse. REF: Page 458-459 | Page 463 (Table 24 - 2)

15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness

ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient 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 patient with borderline personality disorder. REF: Page 476 (Fig 24 - 1)

5. While conducting the initial interview with a patient in crisis, the nurse should: a. speak in short, concise sentences. b. convey a sense of urgency to the patient. c. be forthright about time limits of the interview. d. let the patient know the nurse controls the interview.

ANS: A Severe anxiety narrows perceptions and concentration. By speaking in short, concise sentences, the nurse enables the patient to grasp what is being said. Conveying urgency will increase the patient's anxiety. Letting the patient know who controls the interview or stating that time is limited is nontherapeutic.

3. A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

15. A victim of spousal violence comes to the crisis center seeking help. The nurse uses crisis intervention strategies that focus on: a. supporting emotional security and reestablishing equilibrium b. offering a long-term resolution of issues precipitating the crisis c. promoting growth of the individual d. providing legal assistance

ANS: A Strategies of crisis intervention are directed toward the immediate cause of the crisis and are aimed at bolstering the emotional security and reestablishing equilibrium, rather than focusing on underlying issues and long-term resolutions. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. Promoting growth is a focus of long-term therapy. Providing legal assistance might be applicable.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

9. An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

ANS: A The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

23. Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

ANS: A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.

16. A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

ANS: A The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

19. An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to provide constant supervision. No assessment data support the diagnoses of Impaired verbal communication or Noncompliance. Sleep pattern disturbance certainly applies to this patient; however, the diagnosis Risk for injury is a higher priority.

21. A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

ANS: A The patient will develop a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm the achievement of outcomes.

20. An adult has cared for a debilitated parent for 10 years. The parent's condition has recently declined, and the health care provider has recommended placement in a skilled care facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this person's crisis will most closely relate to: a. resolving the feelings associated with the threat to the person's self-concept b. maintaining the ability to identify situational supports in the community c. relying on the assistance from role models within the person's culture d. mobilizing automatic relief behaviors by the person

ANS: A The patient's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the deteriorating condition, has been challenged. Crisis resolution involves coming to terms with the feelings associated with this loss. Identifying situational supports is relevant but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but is not the primary factor associated with resolution in this case. Automatic relief behaviors are not helpful and are part of the fourth phase of crisis.

20. A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

ANS: A The patient's words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

1. A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

ANS: A The psychologic trauma associated with rape is produced by a number of factors. Of the options given, the threat to life is by far the most traumatic aspect of the crisis. The other options may, however, add significantly to the trauma.

16. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase

ANS: A The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term, or anger phase.

10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

9. What is the priority nursing diagnosis for a patient 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. Patients 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 patients with antisocial personality disorders use denial, they use it effectively. REF: Page 465-467 (Table 24-3)

2. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply. a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

ANS: A, B Delusions of persecution and ideas of reference support the nursing diagnosis of disturbed thought processes. Risk for other-directed violence is substantiated by the patient's feeling endangered by persecutors. Fearful individuals may strike out at perceived persecutors or attempt self-harm to get away from persecutors. Data are not present to support the other diagnoses.

A nurse ends a relationship with a patient. Which actions by the nurse should be included in the termination phase? Select all that apply. a. Focus dialogues with the patient on problems that may occur in the future. b. Help the patient express feelings about the relationship with the nurse. c. Help the patient prioritize and modify socially unacceptable behaviors. d. Reinforce expectations regarding the parameters of the relationship. e. Help the patient to identify strengths, limitations, and problems.

ANS: A, B The correct actions are part of the termination phase. The other actions would be used in the working and orientation phases.

2. Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arms-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 patients eyeglasses to prevent self-injury. e. Interact with the patient 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 patient 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 arms-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arms 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) REF: Page 491-492 (Table 25-5) and (Box 25-4) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

Which benefits are most associated with use of telehealth technologies? Select all that apply. a. Cost savings for patients b. Maximize care management c. Access to services for patients in rural areas d. Prompt reimbursement by third party payers e. Rapid development of trusting relationships with patients

ANS: A, B, C Telehealth has shown it can maximize health and improve disease management skills and confidence with the disease process. Many rural parents have felt disconnected from services; telehealth technologies can solve those problems. Although telehealth's improved health outcomes regularly show cost savings for payers, one significant barrier is the current lack of reimbursement for remote patient monitoring by third party payers. Telehealth technologies have not shown rapid development of trusting relationships.

3. A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by "yes" or "no."

1. A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan is not a priority at this time.

2. A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient's privacy may be compromised by the presence of family. The rape victim's anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

2. For which patients 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.

2. For which patients 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. REF: Page 459-460 | Page 465-466

Select all that apply. 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? The nurse should recommend: (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. e. staying with the child until the anxiety decreases.

ANS: A, B, C, E The child's symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. 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.

MULTIPLE RESPONSE 1. A nurse assesses five newly hospitalized patients. Which patients 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 non-whites, 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) REF: Page 481-485 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2. A nurse directs the intervention team who must take an aggressive patient to seclusion. Other patients were removed from the area. Before approaching the patient, the nurse should ensure that the staff takes which of the following actions? Select all that apply. a. Remove jewelry, glasses, and harmful items from the patient and staff members. b. Appoint a person to clear a path and open, close, or lock doors. c. Quickly approach the patient, and grab the closest extremity. d. Select the person who will communicate with the patient. e. Move behind the patient to use the element of surprise.

ANS: A, B, D Injury to staff members and to the patient should be prevented. Only one person should explain what will happen and direct the patient; this person might be the nurse or staff member who has a good relationship with the patient. A clear pathway is essential; those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering the medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest limb. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

A nurse is interacting with patients in a psychiatric unit. Which statements reflect use of therapeutic communication? Select all that apply. a. "Tell me more about that situation." b. "Let's talk about something else." c. "I notice you are pacing a lot." d. "I'll stay with you a while." e. "Why did you do that?"

ANS: A, C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate changing the subject and probing, which are non-therapeutic techniques.

4. Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? Select all that apply. a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

ANS: A, C, D The patient's behavior, the intervention techniques used, and the environment in which the incident occurred are important to establish realistic outcomes and effective nursing interventions. Discussing views about the theoretical origins of aggression would be less effective and relevant.

1. When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply. a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

ANS: A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

2. The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply) a. rehearsing techniques to handle anticipated stressful situations. b. advising the patient to accept residential treatment if relapse occurs. c. assisting the patient to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

2. A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? Select all that apply. a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

ANS: A, C, E Injury to staff and the patient should be prevented. Only one person should explain what will happen and direct the patient. This may be the nurse or a staff member with a good relationship with the patient. A clear pathway is essential because those restraining a limb cannot use keys, move furniture, or open doors. The nurse is usually responsible for administering medication once the patient is restrained. Each staff member should have an assigned limb rather than just grabbing the closest. This system could leave one or two limbs unrestrained. Approaching in full view of the patient reduces suspicion.

4. Which behaviors are most consistent with the clinical picture of a patient who is becoming increasingly aggressive? Select all that apply. a. Pacing b. Crying c. Withdrawn affect d. Rigid posture with clenched jaw e. Staring with narrowed eyes into the eyes of another

ANS: A, D, E Crying and a withdrawn affect are not cited by experts as behaviors indicating that the individual has a high potential to behave violently. The other behaviors are consistent with the increased risk for other-directed violence.

1. A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would be expected from the driver immediately after this event? Select all that apply. a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

ANS: A, D, E Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

1. A patient with a history of command hallucinations approaches the nurse, yelling obscenities. The patient mumbles and then walks away. The nurse follows. Which nursing actions are most likely to be effective in de-escalating this scenario? Select all that apply. a. State the expectation that the patient will stay in control. b. State that the patient cannot be understood when mumbling. c. Tell the patient, "You are behaving inappropriately." d. Offer to provide the patient with medication to help. e. Speak in a firm but calm voice.

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering an as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

1. A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in de-escalation for this scenario? Select all that apply. a. Stating the expectation that the patient will stay in control b. Asking the patient, "Do you want to go into seclusion?" c. Telling the patient, "You are behaving inappropriately." d. Offering to provide the patient with medication to help e. Speaking in a firm but calm voice

ANS: A, D, E Stating the expectation that the patient will maintain control of behavior reinforces positive, healthy behavior and avoids challenging the patient. Offering as-needed medication provides support for the patient trying to maintain control. A firm but calm voice will likely comfort and calm the patient. Belittling remarks may lead to aggression. Criticism will probably prompt the patient to begin shouting.

3. Which central nervous system structures are most associated with anger and aggression? Select all that apply. a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. Prefrontal cortex

ANS: A, D, E The amygdala and prefrontal cortex mediate anger experiences and help a person judge an event as either rewarding or aversive. The temporal lobe, which is part of the limbic system, also plays a role in aggressive behavior. The basal ganglia are involved in movement. The cerebellum manages equilibrium, muscle tone, and movement.

1. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

ANS: A, E Stabilization is maximized by adherence to the antipsychotic medication regimen. Because so many persons with schizophrenia smoke cigarettes, this topic relates directly to the patients' physiological well-being. The other topics are also important but are not priority topics.

A novice psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls feelings of embarrassment about the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings.Select all that apply. a. Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. b. Recognize that these feelings are unhealthy. The nurse should try to suppress them when working with patients. c. Recognize that psychiatric nursing is not an appropriate career choice. Explore other nursing specialties. d. The nurse should begin new patient relationships by saying, "My own parent had mental illness, so I accept it without stigma." e. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

ANS: A, E The nurse needs support to explore these feelings. An experienced psychiatric nurse is a resource that may be helpful. The knowledge and experience gained from the nurse's relationship with a mentally ill parent may contribute sensitivity to compassionate practice. Self-disclosure and suppression are not adaptive coping strategies. The nurse should not give up on this area of practice without first seeking ways to cope with the memories.

Alicia, a 31 year old patient, is flirting with a peer. She is overheard asking him to convince staff to give her privileges to leave the inpatient mental health unit. Later she offers you a back rub in exchange receiving her 10:00 pm Xanax an hour early. Which responses to such behaviors would be themes therapeutic? Select all that apply. a. label the behavior as undesirable, and explore with alicia more effective ways to meet her needs. b. by role playing, demo other approaches alicia could use to meet her needs c. advise the other patients that alicia is being manipulative and that they should ignore her when she behaves this way d. bargain with alicia to determine a reasonable compromise regarding how much of such behavior is acceptable before she crosses the line e. explain that such behavior is unacceptable, and give alicia specific examples of consequences that will be enacted if the behavior continues f. ignore the behavior for the time being so alicia will find it unrewarding and in turn seek other, and hopefully more adaptive, ways to meet her needs

ANS: A,B,E

A patient becomes frustrated and angry and when trying to get hi MP3 player and headset to function properly and angrily throws it across the room, nearly hitting a peer with it. Which interventions would be the most therapeutic. Select all that apply. a. place the pt in seclusion for an hour to allow him to deescalate b. tell the pt that any further outbursts will result in a loss of privileges c. offer to help the pt learn how to operate his music player and headset d. explore with the pt how he was feeling as he worked with the music player e. point out the consequences of such behavior and note that it cannot be tolerated f. limit the pts exposure to frustrating experiences until he attains improved coping skills g. encourage the pt to recognize signs of escalating tension and seek assistance

ANS: A,D,E,G

Belinda is a 24-year-old patient with borderline personality disorder (BPD). She is admitted to the inpatient psychiatric unit following a suicide attempt. You are caring for Belinda. Which of the following statements by Belinda illustrates a primary coping style of persons with BPD? a. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" b. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." c. "I will never again speak to any of my messed up family members. I know that this will help me be more functional." d. "I promise I am not feeling suicidal. I won't hurt myself."

ANS: B

Josie, a 27 year old patient complains that the most of the staff do not like her or care what happens to her, but you are special and she can tell you that you are a caring person. She talks with you about being unsure of what she want to do with her life and her "mix-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stops." Given the presentation, which personality disorder would you suspect? a. obsessive compulsive b. borderline c. antisocial d. schizotypal

ANS: B

10. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.

ANS: B A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

9. A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers."

ANS: B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

ANS: B Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents...so helpless." Which response is the nurse demonstrating? a. Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction

ANS: B Countertransference is the nurse's transference or response to a patient that is based on the nurse's unconscious needs, conflicts, problems, or view of the world. See relationship to audience response question.

An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? a. "This patient continues to deny problems resulting from drinking." b. "My parents were alcoholics and often neglected our family." c. "The patient cannot identify any goals for improvement." d. "The patient said I have many traits like her mother."

ANS: B Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past. In this instance, the new nurse's irritability stems from relationships with parents. The distracters indicate transference or accurate analysis of the patient's behavior.

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

A nurse wants to demonstrate genuineness with a patient diagnosed with schizophrenia. The nurse should: a. restate what the patient says. b. use congruent communication strategies. c. use self-revelation in patient interactions. d. consistently interpret the patient's behaviors.

ANS: B Genuineness is a desirable characteristic involving awareness of one's own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are undesirable in a therapeutic relationship.

A black patient says to a white nurse, "There's no sense talking. You wouldn't understand because you live in a white world." The nurse's best action would be to: a. explain, "Yes, I do understand. Everyone goes through the same experiences." b. say, "Please give an example of something you think I wouldn't understand." c. reassure the patient that nurses interact with people from all cultures. d. change the subject to one that is less emotionally disturbing.

ANS: B Having the patient speak in specifics rather than globally will help the nurse understand the patient's perspective. This approach will help the nurse engage the patient. Reassurance and changing the subject are not therapeutic techniques.

22. Which statement by a depressed patient will alert the nurse to the patients 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) REF: Page 487-490 (Table 25-3) and (Nursing Care Plan 25-1) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment

23. A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patients roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report 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) REF: Page 487-488 | Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A patient diagnosed with schizophrenia tells the nurse, "The CIA is monitoring us through the fluorescent lights in this room. Be careful what you say." Which response by the nurse would be most therapeutic? a. "Let's talk about something other than the CIA." b. "It sounds like you're concerned about your privacy." c. "The CIA is prohibited from operating in health care facilities." d. "You have lost touch with reality, which is a symptom of your illness."

ANS: B It is important not to challenge the patient's beliefs, even if they are unrealistic. Challenging undermines the patient's trust in the nurse. The nurse should try to understand the underlying feelings or thoughts the patient's message conveys. The correct response uses the therapeutic technique of reflection. The other comments are non-therapeutic. Asking to talk about something other than the concern at hand is changing the subject. Saying that the CIA is prohibited from operating in health care facilities gives false reassurance. Stating that the patient has lost touch with reality is truthful, but uncompassionate.

24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication? a. How to recognize tardive dyskinesia b. Weight management strategies c. Ways to manage constipation d. Sleep hygiene measures

ANS: B Lurasidone HCL (Latuda) is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with this medication. The patient is overweight now, so weight management will be especially important. The incidence of tardive dyskinesia is low with second-generation antipsychotic medications. Constipation may occur, but it is less important than weight management. This drug usually produces drowsiness.

37. A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

ANS: B Magical thinking is evident in the patient's appraisal of his own abilities. There is no evidence of the distracters.

12. What is the most challenging nursing intervention with patients 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 patient's superior skills at manipulation. Supporting behavioral change and monitoring patient 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. See relationship to audience response question.

The patient says, "My marriage is just great. My spouse and I always agree." The nurse observes the patient's foot moving continuously as the patient twirls a shirt button. The conclusion the nurse can draw is that the patient's communication is: a. clear. b. mixed. c. precise. d. inadequate.

ANS: B Mixed messages involve the transmission of conflicting or incongruent messages by the speaker. The patient's verbal message that all was well in the relationship was modified by the nonverbal behaviors denoting anxiety. Data are not present to support the choice of the verbal message being clear, explicit, or inadequate.

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol (Haldol) b. Olanzapine (Zyprexa) c. Chlorpromazine (Thorazine) d. Diphenhydramine (Benadryl)

ANS: B Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.

7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

ANS: B Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

ANS: B Resist focusing on content; instead, focus on the feelings the patient is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase patient anxiety and the tenacity with which the patient holds to the delusion. The other options focus on content and provide opportunity for argument.

6. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n): a. narcotic analgesic, such as hydromorphone (Dilaudid). b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium). c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

1. An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patients history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patients history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 492 TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient 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 assessed as: a. denial. b. splitting c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the patient 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. See relationship to audience response question.

A nurse wants to enhance growth of a patient by showing positive regard. The nurse's action most likely to achieve this goal is: a. making rounds daily. b. staying with a tearful patient. c. administering medication as prescribed. d. examining personal feelings about a patient.

ANS: B Staying with a crying patient offers support and shows positive regard. Administering daily medication and making rounds are tasks that could be part of an assignment and do not necessarily reflect positive regard. Examining feelings regarding a patient addresses the nurse's ability to be therapeutic.

19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

ANS: B Tardive dyskinesia is a neuroleptic-induced condition involving the face, trunk, and limbs. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

ANS: B The correct response indicates the patient is experiencing paranoia. Paranoia often leads to fearfulness, and the patient may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

19. In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

ANS: B The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

10. Select 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 patients 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 patients safety. The information in the other questions may be important to ask but are not the most critical. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 483 (Box 25-2) | Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Safe, Effective Care Environment

30. A patient 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 patients 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 patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse's understanding of the patient'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 patient.

35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

ANS: B The patient is experiencing paranoia and delusional thinking, which leads to fear. Explaining that the patient is in a safe place will help relieve the fear. It is not therapeutic to disagree or give advice. Medication will not relieve the immediate concern.

3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

ANS: B The patient sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the patient. Data are not present to support any of the other options.

27. An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

24. Symptoms of withdrawal from opioids for which the nurse should assess include: a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

ANS: B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

During the first interview with a parent whose child died in a car accident, the nurse feels empathic and reaches out to take the patient's hand. Select the correct analysis of the nurse's behavior. a. It shows empathy and compassion. It will encourage the patient to continue to express feelings. b. The gesture is premature. The patient's cultural and individual interpretation of touch is unknown. c. The patient will perceive the gesture as intrusive and overstepping boundaries. d. The action is inappropriate. Psychiatric patients should not be touched.

ANS: B Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment can be made regarding the way in which the patient will perceive touch. The other options present prematurely drawn conclusions.

11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

ANS: B Waxy flexibility is the ability to hold distorted postures for extended periods of time, as though the patient were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. 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 patients with personality disorders; each might apply to selected clinical diagnoses, but not to others.

1. A patient comes to the clinic with superficial cuts on the left wrist. The patient paces around the room sobbing but cringes when approached and responds to questions with only shrugs or monosyllables. Select the nurse's best initial statement to this patient. a. "Everything is going to be all right. You are here at the clinic, and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

ANS: B A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate the use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the patient's safety, and interpersonal reassurance.

12. Which assessment finding presents the greatest risk for violent behavior directed at others? a. Severe agoraphobia b. History of spousal abuse c. Bizarre somatic delusions d. Verbalized hopelessness and powerlessness

ANS: B A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions.

23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should: a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

ANS: B A matter-of-fact approach does not provide the patient 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. REF: Page 473

7. An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the dayroom. The nurse should enter the day room: a. and say, "Would you like to come to your room and take some medication your health care provider prescribed for you?" b. accompanied by 3 staff members and say, "Please come to your room so I can give you some medication that will help you regain control." c. and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." d. accompanied by a male security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there."

ANS: B A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort.

18. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

4. An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The patient told the parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Adventitious c. Situational d. Organic

ANS: B An adventitious crisis is a crisis of disaster that is not a part of everyday life; it is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. Organic is not a type of crisis.

7. What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

ANS: B Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

24. A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within a period of time specified by the state and the agency. The incorrect options are not immediately necessary from a legal standpoint. See related audience response question.

25. A new patient immediately requires seclusion on admission. The assessment is incomplete, and no prescriptions have been written. Immediately after safely secluding the patient, which action has priority? a. Provide an opportunity for the patient to go to the bathroom. b. Notify the health care provider and obtain a seclusion order. c. Notify the hospital risk manager. d. Debrief the staff.

ANS: B Emergency seclusion can be effected by a credentialed nurse but must be followed by securing a medical order within the period specified by the state and agency. The incorrect options are not immediately necessary from a legal standpoint.

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

18. A patient has a history of impulsively acting out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

ANS: B Identification of trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration, which lead to acting out anger, and eventually to put into practice more adaptive coping strategies.

17. A patient has a history of impulsively acting out anger by striking others. Which would be an appropriate plan for avoiding such incidents? a. Explain that restraint and seclusion will be used if violence occurs. b. Help the patient identify incidents that trigger impulsive acting out. c. Offer one-on-one supervision to help the patient maintain control. d. Give the patient lorazepam (Ativan) every 4 hours to reduce anxiety.

ANS: B Identifying trigger incidents allows the patient and nurse to plan interventions to reduce irritation and frustration that lead to acting out anger and to put more adaptive coping strategies eventually into practice.

15. When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

ANS: B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

5. A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

ANS: B In this situation, the nurse should consider the possibility that the patient is a victim of domestic violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.

3. A patient comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the patient is: a. suicidal. b. anxious and fearful. c. misperceiving reality. d. potentially homicidal.

ANS: B Individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed.

3. What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

ANS: B Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

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

ANS: B Maintaining consistent limits is by far the most difficult intervention because of the patient's superior skills at manipulation. Supporting behavioral change and monitoring patient 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. See relationship to audience response question. REF: Page 463 (Table 24-2) | Page 469 (Table 24-4) | Page 473-474

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient 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. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive. REF: Page 468-469

13. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

14. Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

ANS: B Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

22. An appropriate question for the nurse to ask to assess situational support is: a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

ANS: B Only the correct answer focuses on situational support. The incorrect options focus on the patient's perception of the precipitating event.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

20. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent escalation of anger? a. Explain that the patient's condition is not life threatening. b. Periodically provide an update and progress report on the patient. c. Explain that all patients are treated in order, based on their medical needs. d. Suggest that the spouse return home until the patient's treatment is completed.

ANS: B Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concerns. The incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

14. Which situation demonstrates the use of primary care related to crisis intervention? a. Implementing suicide precautions for a patient with depression. b. Teaching stress reduction techniques to a beginning student nurse. c. Assessing coping strategies used by a patient who has attempted suicide. d. Referring a patient with schizophrenia to a partial hospitalization program.

ANS: B Primary crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary intervention.

15. After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

ANS: B Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The episodes are likely to become increasingly violent. Data are not present that show social isolation or disabled family coping, although both are common among victims of violence. Deficient knowledge does not apply to this patient's use of defense mechanisms.

16. A patient with a history of anger and impulsivity is hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolds the nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Tell the patient to notify nursing staff 30 minutes before the pain returns so the medication can be prepared. b. Urge the health care provider to change the prescription for pain medication from as needed to a regular schedule. c. Tell the patient that verbal assaults on nurses will not shorten the wait for pain medication. d. Have the clinical nurse leader request a psychiatric consultation.

ANS: B Scheduling the medication at specific intervals will help the patient anticipate when the medication can be given. Receiving the medication promptly on schedule, rather than expecting nurses to anticipate the pain level, should reduce anxiety and anger. The patient cannot predict the onset of pain before it occurs.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

24. A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient 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 assessed as: a. denial. b. splitting. c. defensive. d. reaction formation.

ANS: B Splitting involves loving a person, then hating the person because the patient 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. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 470-471

4. Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

ANS: B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to overinvolvement with the victim.

9. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." If this person's immediate family is unable to provide sufficient situational support, the nurse should: a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the patient, "You must be strong. Don't let this crisis overwhelm you." d. foster insight by relating the present situation to earlier situations involving loss.

ANS: B The assessment of situational supports should continue. Although the patient's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

1. A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

ANS: B The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

19. During the initial interview at the crisis center, a patient says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." What could the nurse say to assess personal coping skills? a. "What would you like us to do to help you feel more relaxed?" b. "In the past, how did you handle difficult or stressful situations?" c. "Do you think you deserve to have things like this happen to you?" d. "I can see you are upset. You can rely on us to help you feel better."

ANS: B The correct answer is the only option that assesses coping skills. The incorrect options offer unrealistic reassurance, are concerned with self-esteem, and ask the patient to decide on treatment at a time when he or she "cannot think clearly."

10. An adult patient assaults another patient and is restrained. One hour later, which statement by this restrained patient necessitates the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "It was not my fault. The other patient started it."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate that the patient has continued aggressiveness and agitation.

10. An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? a. "I hate all of you" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "The other patient started the fight."

ANS: B The correct response indicates impaired circulation and necessitates the nurse's immediate attention. The incorrect responses indicate the patient has continued aggressiveness and agitation.

17. A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

6. A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

ANS: B The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for domestic violence.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

28. Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are: 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. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 471-472

13. Which communication technique is used more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

ANS: B The nurse working in crisis intervention must be creative and flexible in looking at the patient's situation and suggesting possible solutions to the patient. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

23. An adult comes to the crisis clinic after being terminated from a job of 15 years. The patient says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Disturbed thought processes

ANS: B The patient describes feelings of the lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The patient's thought processes are not shown to be altered at this point.

30. A patient 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 patients 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 patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurse's understanding of the patient'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 patient. REF: Page 467-468

13. A patient being admitted suddenly pulls a knife from a coat pocket and threatens, "I will kill anyone who tries to get near me." An emergency code is called. The patient is safely disarmed and placed in seclusion. Justification for the use of seclusion is that the patient: a. evidences a thought disorder, rendering rational discussion ineffective. b. presents a clear and present danger to others. c. presents a clear escape risk. d. is psychotic.

ANS: B The patient's threat to kill self or others with the knife he possesses constitutes a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

17. A patient with a history of anger and impulsivity was hospitalized after an accident resulting in injuries. When in pain, the patient loudly scolded nursing staff for "not knowing enough to give me pain medicine when I need it." Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from PRN to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

ANS: B Use of patient-controlled analgesia will help the patient manage the pain. This intervention will help reduce the patient's anxiety and anger. Dependency is not an important concern related to acute pain.

23. A patient with burn injuries has had good coping skills for several weeks. Today, a newly assigned nurse is poorly organized. The patient's usual schedule was not followed. By mid-afternoon, the patient is angry and loudly complains to the nurse manager. Which is the nurse manager's best response? a. Explain the reasons for the disorganization, and take over the patient's care for the rest of the shift. b. Acknowledge and validate the patient's distress and ask, "What would you like to have happen?" c. Apologize and explain that the patient will have to accept the situation for the rest of the shift. d. Ask the patient to control the anger and explain that allowances must be made for new staff members.

ANS: B When a patient with good coping skills is angry and overwhelmed, the goal is to reestablish a means of dealing with the situation. The nurse should solve the problem with the patient by acknowledging the patient's feelings, validating them as understandable, apologizing as necessary, and then seeking an acceptable solution. Often patients can tell the nurse what they would like to have happen as a reasonable first step.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

1. Which descriptors exemplify consistency regarding nurse-patient relationships? Select all that apply. a. Encouraging a patient to share initial impressions of staff b. Having the same nurse care for a patient on a daily basis c. Providing a schedule of daily activities to a patient d. Setting a time for regular sessions with a patient e. Offering solutions to a patient's problems

ANS: B, C, D Consistency implies predictability. Having the same nurse see the patient daily and provide a daily schedule of patient activities and a set time for regular sessions will help a patient predict what will happen during each day and develop a greater degree of security and comfort. Encouraging a patient to share initial impressions of staff and giving advice are not related to consistency and would not be considered a therapeutic intervention.

1. A patient cries as the nurse explores the patient's feelings about the death of a close friend. The patient sobs, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse facilitate communication?Select all that apply. a. "Why do you think you are so upset?" b. "I can see that you feel sad about this situation." c. "The loss of a close friend is very painful for you." d. "Crying is a way of expressing the hurt you are experiencing." e. "Let's talk about something else because this subject is upsetting you."

ANS: B, C, D Reflecting ("I can see that you feel sad," "This is very painful for you") and giving information ("Crying is a way of expressing hurt") are therapeutic techniques. "Why" questions often imply criticism or seem intrusive or judgmental. They are difficult to answer. Changing the subject is a barrier to communication.

4. After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

ANS: B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. "Reported" should be used instead of "alleged." "Penetration" should be used instead of "intercourse." "Declined" should be used instead of "refused."

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.

MULTIPLE RESPONSE 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. REF: Page 463 (Table 24 - 2) | Page 465-466

A novice nurse tells a mentor, "I want to convey to my patients that I am interested in them and that I want to listen to what they have to say." Which behaviors will be helpful in meeting the nurse's goal? Select all that apply. a. Sitting behind a desk, facing the patient b. Introducing self to a patient and identifying own role c. Maintaining control of discussions by asking direct questions d. Using facial expressions to convey interest and encouragement e. Assuming an open body posture and sometimes mirror imaging

ANS: B, D, E Trust is fostered when the nurse gives an introduction and identifies his or her role. Facial expressions that convey interest and encouragement support the nurse's verbal statements to that effect and strengthen the message. An open body posture conveys openness to listening to what the patient has to say. Mirror imaging enhances patient comfort. A desk would place a physical barrier between the nurse and patient. A face-to-face stance should be avoided when possible and a less intense 90- or 120-degree angle used to permit either party to look away without discomfort.

Which behavior shows that a nurse values autonomy? The nurse: a. suggests one-on-one supervision for a patient who has suicidal thoughts. b. informs a patient that the spouse will not be in during visiting hours. c. discusses options and helps the patient weigh the consequences. d. sets limits on a patient's romantic overtures toward the nurse.

ANS: C A high level of valuing is acting on one's belief. Autonomy is supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision. Autonomy or self-determination is not the issue in any of the other behaviors.

10. When a patient 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 patient'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 patient'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 patient is able to behave appropriately.

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response? a. "Accepting gifts violates the policies and procedures of the facility." b. "I'm glad you feel so much better now. Thank you for the beautiful necklace." c. "I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope." d. "Helping people is what nursing is all about. It's rewarding to me when patients recognize how hard we work."

ANS: C Accepting a gift creates a social rather than therapeutic relationship with the patient and blurs the boundaries of the relationship. A caring nurse will acknowledge the patient's gesture of appreciation, but the gift should not be accepted. See relationship to audience response question.

A patient discloses several concerns and associated feelings. If the nurse wants to seek clarification, which comment would be appropriate? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that . . ." d. "Tell me everything from the beginning."

ANS: C Asking, "Am I correct in understanding that..." permits clarification to ensure that both the nurse and patient share mutual understanding of the communication. Asking about common elements encourages comparison rather than clarification. The remaining responses are implied questions that suggest the nurse was not listening.

14. The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should: a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

ANS: C Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.

A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response. a. "Don't talk that way. Of course you will leave here!" b. keep up the good work, and you certainly will." c. "You don't think you're making progress?" d. "Everyone feels that way sometimes."

ANS: C By asking if the patient does not believe that progress has been made, the nurse is reflecting by putting into words what the patient is hinting. By making communication more explicit, issues are easier to identify and resolve. The remaining options are non-therapeutic techniques. Telling the patient not to "talk that way" is disapproving. Saying that everyone feels that way at times minimizes feelings. Telling the patient that good work will always result in success is falsely reassuring.

What is the desirable outcome for the orientation stage of a nurse-patient relationship? The patient will demonstrate behaviors that indicate: a. self-responsibility and autonomy. b. a greater sense of independence. c. rapport and trust with the nurse. d. resolved transference.

ANS: C Development of rapport and trust is necessary before the relationship can progress to the working phase. Behaviors indicating a greater sense of independence, self-responsibility, and resolved transference occur in the working phase.

During which phase of the nurse-patient relationship can the nurse anticipate that identified patient issues will be explored and resolved? a. Preorientation b. Orientation c. Working d. Termination

ANS: C During the working phase, the nurse strives to assist the patient in making connections among dysfunctional behaviors, thinking, and emotions and offers support while alternative coping behaviors are tried.

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient'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 patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients 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. See relationship to audience response question.

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

36. Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

ANS: C Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distracters are positive symptoms of schizophrenia. See relationship to audience response question.

25. A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: a. cross-tolerance. b. substance abuse c. substance addiction. d. substance intoxication.

ANS: C Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.

A patient says, "I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges?" What is the nurse's best response? a. "Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. "That's a good topic for you to discuss with your doctor." d. "Do you think you can't speak to a doctor?".

ANS: C Nurses should encourage patients to work at their optimal level of functioning. A nurse does not act for the patient unless it is necessary. Acting for a patient increases feelings of helplessness and dependency

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

ANS: C Patients 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 patient is displaying the opposite of detached behavior. Guilt is not evident in the comments.

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 Patients 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.

9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

ANS: C Physiological needs must be met to preserve life. A patient with waxy flexibility must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Higher level needs are of lesser concern.

16. A patient diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

ANS: C Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

Which issues should a nurse address during the first interview with a patient with a psychiatric disorder? a. Trust, congruence, attitudes, and boundaries b. Goals, resistance, unconscious motivations, and diversion c. Relationship parameters, the contract, confidentiality, and termination d. Transference, countertransference, intimacy, and developing resources

ANS: C Relationship parameters, the contract, confidentiality, and termination are issues that should be considered during the orientation phase of the relationship. The remaining options are issues that are dealt with later.

16. Which statement made by a patient 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.

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions? a. A nurse is responsible for breaking silences. b. Patients withdraw if silences are prolonged. c. Silence can provide meaningful moments for reflection. d. Silence helps patients know that what they said was understood.

ANS: C Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. A nurse breaking silences is not a principle related to silences. It is inaccurate to say that patients withdraw during long silences or that silence helps patients know that they are understood. Feedback helps patients know they have been understood.

15. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."

ANS: C Staying with a distraught patient who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the patient hears voices is not particularly relevant at this point. Asking if the patient plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the patient while encouraging a focus on their discussion. Suggesting playing cards with other patients shifts responsibility for intervention from the nurse to the patient and other patients.

After several therapeutic encounters with a patient who recently attempted suicide, which occurrence should cause the nurse to consider the possibility of countertransference? a. The patient's reactions toward the nurse seem realistic and appropriate. b. The patient states, "Talking to you feels like talking to my parents." c. The nurse feels unusually happy when the patient's mood begins to lift. d. The nurse develops a trusting relationship with the patient.

ANS: C Strong positive or negative reactions toward a patient or over-identification with the patient indicate possible countertransference. Nurses must carefully monitor their own feelings and reactions to detect countertransference and then seek supervision. Realistic and appropriate reactions from a patient toward a nurse are desirable. One incorrect response suggests transference. A trusting relationship with the patient is desirable. See relationship to audience response question.

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) REF: Page 493-494 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

12. A nurse and patient construct a no-suicide contract. Select the preferable wording. 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 patient 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 patient may call a therapist and leave the telephone to carry out the suicidal plan. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 491-492 (Table 26-5) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, I am considering committing suicide. a. Im 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 patient 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 patients ambivalence and sets the stage for more realistic problem solving. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 484 | Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient 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 patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "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 for the patient's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. See relationship to audience response question.

31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C The patient 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 patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient 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 patient's ability to weigh alternatives to mutilating behavior.

27. A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient 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 patient 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.

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

13. A tearful, anxious patient at the outpatient clinic reports, I should be dead. The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.

ANS: C This scenario presents a potential crisis. Establishing rapport 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) REF: Page 488-491 (Nursing Care Plan 25-1) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, My business is bankrupt, and I was served with divorce papers. Which subsequent statement by the patient 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 patients suicide as being a way to fix everything but does not say it outright. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 485-486 | Page 490 (Table 25-3) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

Documentation in a patient's chart shows, "Throughout a 5-minute interaction, patient fidgeted and tapped left foot, periodically covered face with hands, and looked under chair while stating, 'I enjoy spending time with you.'" Which analysis is most accurate? a. The patient is giving positive feedback about the nurse's communication techniques. b. The nurse is viewing the patient's behavior through a cultural filter. c. The patient's verbal and nonverbal messages are incongruent. d. The patient is demonstrating psychotic behaviors.

ANS: C When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent. Some clinicians call it a "mixed message." It is inaccurate to say that the patient is giving positive feedback about the nurse's communication techniques. The concept of a cultural filter is not relevant to the situation because a cultural filter determines what we will pay attention to and what we will ignore. Data are insufficient to draw the conclusion that the patient is demonstrating psychotic behaviors.

10. When a patient 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 patient'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 patient'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 patient is able to behave appropriately. REF: Page 468 (Box 24 - 2) | Page 473-474

8. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

ANS: C A reflective communication technique is helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim's perceived role and interfere with further discussion.

19. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me. You are so stupid. You will make it worse" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "This dressing change is needed so your wound will not get infected." d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your health care provider ordered this dressing change."

ANS: C Anger is cognitively driven. The answer helps the patient test his cognitions and may lead to lowering his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.

18. A patient with severe injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which intervention uses a cognitive technique to help the patient? a. Wordlessly discontinue the dressing change, and then leave the room. b. Stop the dressing change, saying, "Perhaps you would like to change your own dressing." c. Continue the dressing change, saying, "Do you know this dressing change is needed so your wound will not get infected?" d. Continue the dressing change, saying, "Unfortunately, you have no choice in this because your doctor ordered this dressing change."

ANS: C Anger is cognitively driven. The correct answer helps the patient test his cognitions and may help lower his anger. The incorrect options will escalate the patient's anger by belittling or escalating the patient's sense of powerlessness.

4. A confused older adult patient in a skilled care facility is in bed sleeping. The nurse enters the room quietly and touches the bed to see if it is wet. The patient awakens and hits the nurse in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled care facilities increases individual tendencies toward violence. c. The patient interpreted the health care worker's behavior as potentially harmful. d. This patient learned violent behavior by watching other patients act out.

ANS: C Confused patients are not always able to evaluate accurately the actions of others. This patient behaved as though provoked by the intrusive actions of the staff member.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

2. An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

ANS: C Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient'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 patient's attempts to split staff and set them against one another, causing interpersonal conflict. Patients 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. See relationship to audience response question. REF: Page 473-474

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

8. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "Hey, what's going on?" b. "Please quiet down immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

ANS: C Intervention should begin with an analysis of the patient and situation. With this response, the nurse is attempting to hear the patient's feelings and concerns, which leads to the next step of planning an intervention.

5. A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "What is going on?" b. "Please be quiet and sit down in this chair immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

ANS: C Intervention should begin with analysis of the patient and the situation. When anger is escalating, a patient's ability to process decreases. It is important to speak to the patient slowly and in short sentences, using a low and calm voice. Use open-ended statements designed to hear the patient's feelings and concerns. This leads to the next step of planning an intervention.

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters. REF: Page 468 (Box 24-2) | Page 469 (Table 24-4)

16. After celebrating a 40th birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Adventitious

ANS: C Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual, such as divorce and job loss. No classification called reactive crisis exists. Adventitious crises occur when disasters such as natural disasters (e.g., floods, hurricanes), war, or violent crimes disrupt coping styles.

11. A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

ANS: C Obtaining the victim's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.

19. Which medication should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. lithium (Eskalith) b. trazodone (Desyrel) c. olanzapine (Zyprexa) d. valproic acid (Depakene)

ANS: C Olanzapine is a short-acting antipsychotic drug that is useful in calming angry, aggressive patients regardless of their diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for patients with bipolar disorder. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for patients with bipolar disorder or for those who are borderline bipolar.

20. Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? a. Lithium (Eskalith) b. Trazodone (Desyrel) c. Olanzapine (Zyprexa) d. Valproic acid (Depakene)

ANS: C Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is for patients with depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

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

ANS: C Patients 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 patient is displaying the opposite of detached behavior. Guilt is not evident in the comments. REF: Page 459-460 | Page 469 (Table 24 - 4)

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performs many rituals c. Paranoid delusions of being followed by alien monsters d. Completed alcohol withdrawal; beginning a rehabilitation program

ANS: C Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability.

23. Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in: a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

ANS: C Patients whose personality style causes them to externalize blame see the source of their discomfort and anxiety as being outside themselves. They displace anger and are often unable to self-soothe. The incorrect options are less likely to have a bearing on this behavior.

21. An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient's treatment is complete.

ANS: C Periodic updates reduce anxiety and defuse anger. This strategy acknowledges the spouse's presence and concern. A cup of coffee is a nice gesture, but it does not address the spouse's feelings. The other incorrect options would be likely to increase anger because they imply that the anxiety is inappropriate.

16. Which statement made by a patient 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. REF: Page 470-471 | Page 473-474 (Case Study and Nursing Care Plan 24-1)

18. Which agency provides coordination in the event of a terrorist attack? a. U.S. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

ANS: C The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

17. An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: C The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

2. Which scenario predicts the highest risk for directing violent behavior toward others? a. Major depression with delusions of worthlessness b. Obsessive-compulsive disorder; performing many rituals c. Paranoid delusions of being followed by alien monsters d. Completing alcohol withdrawal and beginning a rehabilitation program

ANS: C The correct answer illustrates the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The patients identified in the distracters have better reality-testing ability.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. Feelings of revenge create a risk for harm to the patient. The distracters are normal in a person who was assaulted. They usually are relieved with crisis intervention, help the individual regain a sense of control, and make sense of the event.

8. After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse says, "I dread facing potentially violent patients." Which response would be the most urgent reason for this nurse to seek supervision? a. Startle reactions b. Difficulty sleeping c. Wish for revenge d. Preoccupation with the incident

ANS: C The desire for revenge signals an urgent need for professional supervision to work through anger and counter the aggressive feelings. The distracters are normal in a person who has been assaulted. Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the individual regain a sense of control, and make sense of the event.

22. When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might refuse to have evidence collected or to involve law enforcement.

14. An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

ANS: C The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by: 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. REF: Page 465-466

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient 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 patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "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 for the patient's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. See relationship to audience response question. REF: Page 463 (Table 24 - 2) | Page 466-467 | Page 469 (Table 24 - 4)

26. At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me feel like my life is back in balance." The nurse responds, "I think it would be worthwhile to have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The patient is experiencing transference. b. The patient demonstrates a need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the patient's feelings of dependency.

ANS: C The nurse's remark is clearly an invitation to work on other problems and prolong contact with the patient. The focus of crisis intervention is on the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The patient's need for continuing support is not demonstrated in the scenario. The scenario does not describe dependency needs.

11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should: a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an anti-anxiety medication to decrease the anxiety level.

ANS: C The patient 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 patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient 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 patient's ability to weigh alternatives to mutilating behavior. REF: Page 460 | Page 476

27. A new psychiatric technician says, "Schizophrenia...schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient 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 patient 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. REF: Page 457-458 | Page 463 (Table 24 - 2)

12. A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.

ANS: C The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. 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 patient would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control. REF: Page 463 (Table 24-5) | Page 466-467 | Page 469 (Table 24-4)

12. An adult tells the nurse, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter told me she's quitting college and moving in with her boyfriend." What is the priority nursing diagnosis? a. Fear, related to impending surgery b. Deficient knowledge, related to breast lesion c. Ineffective coping, related to perceived loss of daughter d. Impaired verbal communication, related to spousal estrangement

ANS: C This nursing diagnosis is the priority because it reflects the precipitating event associated with the patient's crisis. Data are not present to make the other diagnoses of Deficient knowledge, Fear, or Impaired verbal communication.

16. A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Your husband gets angry if you do not have dinner ready on time?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The distracters do not validate the patient's feelings.

15. A cognitively impaired patient has been a widow for 30 years. This patient is frantically trying to leave the unit, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse should say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Was your husband angry if you did not have dinner ready on time?"

ANS: C Validation therapy meets the patient "where she or he is at the moment" and acknowledges the patient's wishes. Validation does not seek to redirect, reorient, or probe. The other options do not validate patient feelings.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

4. A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

ANS: C, D The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

Which comments by a nurse demonstrate use of therapeutic communication techniques? Select all that apply. a. "Why do you think these events have happened to you?" b. "There are people with problems much worse than yours." c. "I'm glad you were able to tell me how you felt about your loss." d. "I noticed your hands trembling when you told me about your accident." e. "You look very nice today. I'm proud you took more time with your appearance."

ANS: C, D The correct responses demonstrate use of the therapeutic techniques making an observation and showing empathy. The incorrect responses demonstrate minimizing feelings, probing, and giving approval, which are non-therapeutic techniques.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

Select all that apply. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? 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.

Lacey, a 19 year old, shows you multiple fresh, serious (but non life threatening) self-inflicted cuts on her forearms. Which response would bet he most therapeutic? a. im so sorry you felt so bad that you cut yourself lets discuss what led up to this action while i take care of your wounds b. i will take care of your wounds first then you will have to be searched for anything else you could injure yourself with c. i can give you some bandaids for you to put on your cuts, but you need to stop this attention seeking behavior d. after i care for your wounds i would like you to write down what you were feeling and thinking before you cut yourself. then we will discuss it.

ANS: D

Mary Alice is a 37-year-old patient referred to the mental health clinic with a suspected personality disorder. She is withdrawn and suspicious and states she has always preferred to be alone. She describes herself as having "special powers" and states that she is thinking of opening a business where she gives "readings" to people about their future. She states, "I believe we can all read each other's thoughts at times." Based on this presentation, you suspect: a. obsessive-compulsive personality disorder. b. narcissistic personality disorder. c. avoidant personality disorder. d. schizotypal personality disorder (STPD).

ANS: D

A nurse interacts with a newly hospitalized patient. Select the nurse's comment that applies the communication technique of "offering self." a. "I've also had traumatic life experiences. Maybe it would help if I told you about them." b. "Why do you think you had so much difficulty adjusting to this change in your life?" c. "I hope you will feel better after getting accustomed to how this unit operates." d. "I'd like to sit with you for a while to help you get comfortable talking to me."

ANS: D "Offering self" is a technique that should be used in the orientation phase of the nurse-patient relationship. Sitting with the patient, an example of "offering self," helps to build trust and convey that the nurse cares about the patient. Two incorrect responses are ineffective and non-therapeutic. The other incorrect response is therapeutic but is an example of "offering hope."

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine (Clozaril) b. Ziprasidone (Geodon) c. Olanzapine (Zyprexa) d. Aripiprazole (Abilify)

ANS: D Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a patient with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a patient with cardiac disease. Olanzapine fosters weight gain.

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: 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 patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.

26. Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use. (Educators may alter this question to multiple answers if desired.)

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 twelve 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) REF: Page 482-483 (Box 25-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

ANS: D Improved social skills help patients maintain relationships with others. These relationships are important to management of the disorder. Most patients with schizophrenia think concretely, so insight development is unlikely. Not all patients with schizophrenia experience delusions.

31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

ANS: D Learning what a command hallucination is telling the patient to do is important because the command often places the patient or others at risk for harm. Command hallucinations can be terrifying and may pose a psychiatric emergency. The incorrect questions are of lesser importance than identifying the command.

25. A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

ANS: D Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient's behavior? The patient: a. has a histrionic personality disorder. b. believes dramatic body language is sexually appealing. c. wishes to impress staff with the degree of emotional pain. d. belongs to a culture in which dramatic body language is the norm.

ANS: D Members of Hispanic American subcultures tend to use high affect and dramatic body language as they communicate. The other options are more remote possibilities.

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

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 should get the money." These statements show: 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 patient's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.

22. A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. 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 usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a. the need for psychoeducation. b. medication noncompliance. c. chronic deterioration. d. relapse.

ANS: D Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication noncompliance may not be implicated. Relapse can occur even when the patient is taking medication regularly. Psychoeducation is more effective when the patient's symptoms are stable. Chronic deterioration is not the best explanation.

8. A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise 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: Apply (Application) REF: Page 487 | Page 492 (Table 25-4) TOP: Nursing Process: Outcomes Identification MSC: Client Needs: Psychosocial Integrity

A Filipino American patient had a nursing diagnosis of situational low self-esteem related to poor social skills as evidenced by lack of eye contact. Interventions were used to raise the patient's self-esteem, but after 3 weeks, the patient's eye contact did not improve. What is the most accurate analysis of this scenario? a. The patient's eye contact should have been directly addressed by role-playing to increase comfort with eye contact. b. The nurse should not have independently embarked on assessment, diagnosis, and planning for this patient. c. The patient's poor eye contact is indicative of anger and hostility that were unaddressed. d. The nurse should have assessed the patient's culture before making this diagnosis and plan.

ANS: D The amount of eye contact a person engages in is often culturally determined. In some cultures, eye contact is considered insolent, whereas in others eye contact is expected. Asian Americans, including persons from the Philippines, often prefer not to engage in direct eye contact.

17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include: 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 patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

8. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

19. A nurse counsels a patient with recent suicidal ideation. Which is the nurses most therapeutic comment? a. Lets make a list of all your problems and think of solutions for each one. b. Im happy youre 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. Lets consider which problems are very important and which are less important.

ANS: D The nurse helps the patient develop effective coping skills. Assist the patient 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) REF: Page 484 | Page 488-489 (Nursing Care Plan 25-1) | Page 491-492 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A nurse caring for a withdrawn, suspicious patient recognizes development of feelings of anger toward the patient. The nurse should: a. suppress the angry feelings. b. express the anger openly and directly with the patient. c. tell the nurse manager to assign the patient to another nurse. d. discuss the anger with a clinician during a supervisory session.

ANS: D The nurse is accountable for the relationship. Objectivity is threatened by strong positive or negative feelings toward a patient. Supervision is necessary to work through countertransference feelings.

30. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

ANS: D The patient is describing phenomena that indicate personal boundary difficulties and depersonalization. The nurse should maintain appropriate social distance and not touch the patient because the patient is anxious about the inability to maintain ego boundaries and merging or being swallowed by the environment. Physical closeness or touch could precipitate panic.

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

ANS: D The patient is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the patient's laughter) and then elicit the patient's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the patient is probably not focusing on what the nurse said in the first place.

5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.

23. A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

ANS: D The patient's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

A patient says to the nurse, "I dreamed I was stoned. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response should the nurse use to clarify the patient's comment? a. "It sounds as though you were uncomfortable with the content of your dream." b. "I understand what you're saying. Bad dreams leave me feeling tired, too." c. "So you feel as though you did not get enough quality sleep last night?" d. "Can you give me an example of what you mean by 'stoned'?"

ANS: D The technique of clarification is therapeutic and helps the nurse examine the meaning of the patient's statement. Asking for a definition of "stoned" directly asks for clarification. Restating that the patient is uncomfortable with the dream's content is parroting, a non-therapeutic technique. The other responses fail to clarify the meaning of the patient's comment.

Which remark by a patient indicates passage from orientation to the working phase of a nurse-patient relationship? a. "I don't have any problems." b. "It is so difficult for me to talk about problems." c. "I don't know how it will help to talk to you about my problems." d. "I want to find a way to deal with my anger without becoming violent."

ANS: D Thinking about a more constructive approach to dealing with anger indicates a readiness to make a behavioral change. Behavioral change is associated with the working phase of the relationship. Denial is often seen in the orientation phase. It is common early in the relationship, before rapport and trust are firmly established, for a patient to express difficulty in talking about problems. Stating skepticism about the effectiveness of the nurse-patient relationship is more typically a reaction during the orientation phase.

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) REF: Page 486-487 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient 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 patients 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 patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.

3. Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients 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) REF: Page 487-488 TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment

A patient says, "People should be allowed to commit suicide without interference from others." A nurse replies, "You're wrong. Nothing is bad enough to justify death." What is the best analysis of this interchange? a. The patient is correct. b. The nurse is correct. c. Neither person is correct. d. Differing values are reflected in the two statements.

ANS: D Values guide beliefs and actions. The individuals stating their positions place different values on life and autonomy. Nurses must be aware of their own values and be sensitive to the values of others.

During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying: a. "Why do you keep asking about me?" b. "Nurses direct the interviews with patients." c. "Do not ask questions about my personal life." d. "The time we spend together is to discuss your concerns."

ANS: D When a patient tries to focus on the nurse, the nurse should refocus the discussion back onto the patient. Telling the patient that interview time should be used to discuss patient concerns refocuses discussion in a neutral way. Telling patients not to ask about the nurse's personal life shows indignation. Saying that nurses prefer to direct the interview reflects superiority. "Why" questions are probing and non-therapeutic.

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

ANS: D When a patient's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the patient that he or she is having difficulty understanding what the patient is saying. If a theme is discernible, ask the patient to talk about the theme. The incorrect options tend to place blame for the poor communication with the patient. The correct response places the difficulty with the nurse rather than being accusatory. See relationship to audience response question.

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent most of the session. Another patient comes to the door of the room, interrupts, and says to the nurse, "I really need to talk to you." The nurse should: a. invite the interrupting patient to join in the session with the current patient. b. say to the interrupting patient, "I am not available to talk with you at the present time." c. end the unproductive session with the current patient and spend time with the interrupting patient. d. tell the interrupting patient, "This session is 5 more minutes; then I will talk with you."

ANS: D When a specific duration for sessions has been set, the nurse must adhere to the schedule. Leaving the first patient would be equivalent to abandonment and would destroy any trust the patient had in the nurse. Adhering to the contract demonstrates that the nurse can be trusted and that the patient and the sessions are important. The incorrect responses preserve the nurse-patient relationship with the silent patient but may seem abrupt to the interrupting patient, abandon the silent patient, or fail to observe the contract with the silent patient.

14. Withdrawn patients diagnosed with schizophrenia: a. are usually violent toward caregivers. b. universally fear sexual involvement with therapists. c. exhibit a high degree of hostility as evidenced by rejecting behavior. d. avoid relationships because they become anxious with emotional closeness.

ANS: D When an individual is suspicious and distrustful and perceives the world and the people in it as potentially dangerous, withdrawal into an inner world can be a defense against uncomfortable levels of anxiety. When someone attempts to establish a relationship with such a patient, the patient's anxiety rises until trust is established. There is no evidence that withdrawn patients with schizophrenia universally fear sexual involvement with therapists. In most cases, it is untrue that withdrawn patients with schizophrenia are commonly violent or exhibit a high degree of hostility by demonstrating rejecting behavior.

2. A patient comes to the clinic with superficial cuts on the left wrist. The patient is pacing and sobbing. After a few minutes with the nurse, the patient is calmer. What should the nurse ask to determine the patient's perception of the precipitating event? a. "Tell me why you were crying." b. "How did your wrist get injured?" c. "How can I help you feel more comfortable?" d. "What was happening just before you started to feel this way?"

ANS: D A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events permits the assessment of the precipitating event. Asking "why" questions is a poor communication technique.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

4. A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled nursing facilities increases an individual's tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAP's behavior as potentially harmful.

ANS: D Confused patients are not always able to evaluate the actions of others accurately. This patient behaved as though provoked by the intrusive actions of the staff.

3. A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence

ANS: D Defining characteristics for risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. There is no indicator that the patient will experience injury. Ineffective coping and impaired social interaction have lower priorities.

12. An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

ANS: D Documentation of the injuries provides a basis for possible legal intervention. The abused adult will need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

8. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identifying measures useful to help improve the couple's communication b. Discussing the patient's feelings about the possibility of having a mastectomy c. Determining whether the husband is still engaged in an extramarital affair d. Clarifying what the patient means by, "I can't take it anymore!"

ANS: D During crisis intervention, the priority concern is patient safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the patient sought help.

22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to: 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 patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth. REF: Page 465 | Page 472 (Evidence Based Practice Box)

19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include: 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. (The educator may reformat this question as multiple response.) REF: Page 458-459 | Page 463 (Table 24 - 2)

11. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

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 should get the money." These statements show: 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 patient's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown. REF: Page 469 (Table 24 - 4)

29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will: a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. 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 usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative. REF: Page 457-458 | Page 463 (Table 24 - 2)

24. When a patient's aggression quickly escalates, which principle applies to the selection of nursing interventions? a. Staff members should match the patient's affective level and tone of voice. b. Ask the patient what intervention would be most helpful. c. Immediately use physical containment measures. d. Begin with the least restrictive measure possible.

ANS: D Standards of care require that staff members use the least restrictive measure possible. This becomes the guiding principle for intervention. Physical containment is seldom the least restrictive measure. Asking the out-of-control patient what to do is rarely helpful. It may be an effective strategy during the preaggressive phase but is less effective during escalation.

3. A patient is hospitalized after an arrest for breaking windows in the home of a former domestic partner. The history reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Posttrauma response c. Disturbed thought processes d. Risk for other-directed violence

ANS: D The defining characteristics for Risk for other-directed violence include a history of being abused as a child, having committed other violent acts, and demonstrating poor impulse control. The defining characteristics for the other diagnoses are not present in this scenario.

14. A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working though angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

14. A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. The patient is: a. demonstrating withdrawal. b. working through angry feelings. c. attempting to use relaxation strategies. d. exhibiting clues to potential aggression.

ANS: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing.

10. A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should be the focus for crisis intervention? a. Possible mastectomy b. Disordered family communication c. Effects of the husband's infidelity d. Coping with the reaction to the daughter's events

ANS: D The focus of crisis intervention is on the most recent problem—"the straw that broke the camel's back." The patient has coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurs only with the introduction of the daughter leaving college and moving.

6. An adult seeks counseling after the spouse is murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

ANS: D The highest nursing priority is safety. The nurse should assess suicidal and homicidal potentials. The incorrect options are important but not the highest priority.

10. An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.

22. Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of: a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.

ANS: D The nurse should suspect marginal coping skills in a patient with substance abuse. They are often anxious, may be concerned about inadequate pain relief, and may have personality styles that externalize blame. The incorrect options do not signal as high a degree of risk as substance abuse.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

25. After completing the contracted number of visits to the crisis clinic, an adult says, "I've emerged from this as a stronger person. You supported me while I worked through my feelings of loss and helped me find community resources. I'm benefiting from a support group." The nurse can evaluate the patient's feelings about the care received as: a. not at all satisfied b. somewhat satisfied c. moderately satisfied d. very satisfied

ANS: D The patient mentions a number of indicators that suggest a high degree of satisfaction with the Nursing Outcomes Classification of patient satisfaction: psychologic care. No indicators express low-to-moderate satisfaction.

8. A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient 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 patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common. REF: Page 463 (Table 24-2) | Page 465-466 | Page 469 (Table 24-4)

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

13. An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient: a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

ANS: D The patient's threat to kill self or others with the knife he possessed constituted a clear and present danger to self and others. The distracters are not sufficient reasons for seclusion.

18. For which behavior would limit setting be most essential? The patient who: a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient 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 patients 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 patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance. REF: Page 468-469 (Box 24 - 2)

3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply) a. administration of naloxone (Narcan). b. vitamin B12 and folate supplements. c. restoring nutritional integrity. d. management of heart rate. e. environmental safety.

ANS: D, E Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

Which of the following are true of antisocial personality disorder (APD)? (select all that apply): a. It is the least studied of the personality disorders. b. It is characterized by rigidity and inflexible standards of self and others. c. Persons with APD display magical thinking. d. Persons with APD are concerned with personal pleasure and power. e. It is characterized by deceitfulness, disregard for others, and manipulation. f. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. g. Frontal lobe dysfunction is a brain change identified in APD.

ANS: D,E,G

What is the underlying problem with the impulse control difficulties?

Anxiety - their actions relieve anxiety or cause pleasure

What's the difference between arson and pyromania?

Arson: causing harm or destruction for monetary gain Pyromania: lowers anxiety or gives sexual arousal or pleasure

A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." She also states that her significant other "keeps nagging at my oldest son, which makes me mad, since he's my son, not his." Which of the following should the nurse recommend to promote a change in the client's situation? A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.

B

A nurse is caring for a client who is on lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements by the nurse is appropriate? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

B

A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety. Which action should the nurse perform first? a.Verify the patient's learning style. b.Lower the patient's current anxiety. c.Create outcomes and a teaching plan. d.Assess how the patient uses defense mechanisms.

B A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Use of defense mechanisms does not apply.

A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? a.Offering hope allays and defuses the patient's anxiety. b.Concerns stated aloud become less overwhelming and help problem solving begin. c.Anxiety is reduced by focusing on and validating what is occurring in the environment. d.Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

B All principles listed are valid, but the only rationale directly related to the intervention of assisting the patient to talk about feelings and concerns is the one that states that concerns spoken aloud become less overwhelming and help problem solving begin.

A patient performs ritualistic hand washing. Which action should the nurse implement to help the patient develop more effective coping? a.Allow the patient to set a hand-washing schedule. b.Encourage the patient to participate in social activities. c.Encourage the patient to discuss hand-washing routines. d.Focus on the patient's symptoms rather than on the patient.

B Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping. Daily activities prevent constant focus on anxiety and symptoms. The other interventions focus on the compulsive symptom. See relationship to audience response question.

A woman is 5'7", 160 lbs, and wears a size 8 shoe. She says, "My feet are huge. I've asked three orthopedists to surgically reduce my feet." This person tries to buy shoes to make her feet look smaller and, in social settings, conceals both feet under a table or chair. Which health problem is likely? a.Social anxiety disorder b.Body dysmorphic disorder c.Separation anxiety disorder d.Obsessive-compulsive disorder due to a medical condition

B Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in a normal-appearing person. The patient's feet are proportional to the rest of the body. In obsessive-compulsive or related disorder due to a medical condition, the individual's symptoms of obsessions and compulsions are a direct physiological result of a medical condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety or fear provoked by exposure to a social or a performance situation that will be evaluated negatively by others. People with separation anxiety disorder exhibit developmentally inappropriate levels of concern over being away from a significant other.

A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a. Reassure the patient that all nurses are skilled in providing postoperative care. b. Present the information again in a calm manner using simple language. c. Tell the patient that staff is prepared to promote recovery. d. Encourage the patient to express feelings to family.

B Giving information in a calm, simple manner will help the patient grasp the important facts. Introducing extraneous topics as described in the distracters will further scatter the patient's attention.

A patient experiences a sudden episode of severe anxiety. Of these medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic? a.buspirone (BuSpar) c.amitriptyline (Elavil) b.lorazepam (Ativan) d.desipramine (Norpramin)

B Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication. Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are tricyclic antidepressants and considered second- or third-line agents.

A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty understanding the nurse's comments and asks, "What do you mean? What are they going to do?" Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the patient's level of anxiety? a.Mild b.Moderate c.Severe d.Panic

B Moderate anxiety causes the individual to grasp less information and reduces problem-solving ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety results in disorganized behavior.

A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

B A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 255 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260 TOP: Nursing Process: Diagnosis/Analysis

The highest degree of credibility is required by a nurse who provides testimony before the court as a(n): a. fact witness. b. expert witness. c. correctional nurse. d. critical care nurse.

B An expert witness is recognized by the court as having a higher level of skill or expertise in a specific area. In addition to testifying about involvement with the individual and documentation of the interactions, an expert witness is permitted by the court to give a professional opinion. A fact witness may testify only regarding what was seen, heard, performed, or documented regarding first-hand nursing care. Correctional and critical care nurses may testify as fact witnesses.

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

B Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy." PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 250 | Page 264 TOP: Nursing Process: Assessment

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

B Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-3) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Planning

A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

During arraignment, a defendant behaves bizarrely, fails to respond to the judge's questions, and shouts obscenities. The judge orders an evaluation by a forensic nurse examiner. Which information provided by the examiner will be most important to the court at this time? a. The defendant's mental state at the time of the crime b. The defendant's competence to proceed with trial c. The cause of the defendant's courtroom behavior d. The defendant's history and cognitive abilities

B Competence to proceed refers to one's capacity to assist the attorney and understand legal proceedings. In the United States, no one is tried unless deemed competent. An incompetent individual is remanded to a locked facility for treatment to regain competency. The court will desire a full assessment of the patient's present mental state related to his ability to assist in his own defense, but at this time, the court is not interested in his state of mind at the time of the original crime nor his history.

Health problems most commonly encountered by correctional nurses are: a. routine infections and minor trauma. b. chronic medical and psychiatric disorders. c. similar to the non-incarcerated population. d. injuries acquired during arrest or incarceration.

B Correctional nurses provide care for inmates who have disproportionately high rates of mental illness, substance abuse, tuberculosis, AIDS, hepatitis, diabetes, and other chronic disorders and infections. The health problems of inmates are more complex and chronic, not similar to their non-incarcerated peers. Trauma is an important issue that affects inmate health, but it is not the primary health issue for this population as a whole.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

B During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 271-272 TOP: Nursing Process: Planning

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 (Table 28-3) TOP: Nursing Process: Assessment

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

B Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257-258 TOP: Nursing Process: Assessment

A correctional nurse working in a county jail assesses all new inmates who report taking psychotropic medication or have symptoms of psychiatric disorders. Because of the high volume of newly incarcerated individuals, which skill is most essential for this nurse? A. Documenting information that could be used as trial evidence B. Quickly and skillfully assessing risks for suicide and violence C. Having a comprehensive understanding of community resources D. Counseling inmates to promote successful adaptation to incarceration

B Newly incarcerated prisoners are often in crisis and may be suicidal. Others may be mentally ill and experiencing relapse. Therefore, being able to quickly and skillfully assess for risk of suicide and violence is an essential skill for the correctional nurse. Documenting potential evidence may occur but is not typically the primary or priority role of a correctional nurse. Community resources and counseling are helpful but would not be a priority compared to risk assessment and reduction.

An older adult with Alzheimer's disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Multiple caregivers b. Alzheimer's disease c. Living in a rural area d. Being part of a busy family

B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534-535 TOP: Nursing Process: Assessment

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

B Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 266 (Table 14-6) | Page 268-269 | Page 270 (Table 14-8) TOP: Nursing Process: Planning

A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Implementation

MULTIPLE CHOICE 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. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains

B Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their concerns and display more obsessive attention to detail, whereas the patient with conversion (functional neurological) disorder often exhibits 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) REF: Page 325-327 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 15. A patient 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

B Patients 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) REF: Page 325-326 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 3. A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably: 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.

B Patients 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 patients reject both. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325 TOP: Nursing Process: Planning

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

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 patients 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). See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 325-326 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 18. A patient says, "I know I have a brain tumor despite the results of the 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."

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) REF: Page 331-334 TOP: Nursing Process: Implementation

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for patients.

B Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 540-541 TOP: Nursing Process: Planning

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.

B The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child's complaints and 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.

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

B The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14?6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

In which circumstance would a psychiatric forensic nurse examiner determine it appropriate for a defendant and attorney to consider the insanity defense? At the time of the crime, the defendant: a. shot a drug dealer who tried to overcharge for cocaine. b. acted on auditory hallucinations of the voice of God commanding, "Kill the children." c. tampered with the brakes on his wife's car after discovering she had an extramarital affair. d. was frightened because of a home robbery the preceding night, assumed a family member was another burglar, and shot him.

B The defendant, demonstrating symptoms of psychosis and acting on the direction of command hallucinations, could use the defense of legal insanity because he was unable to recognize his action as wrong due to a psychiatric illness. The other options suggest the defendant knew right from wrong, had the capacity to know the nature and quality of the act, and had the capacity to form intent to commit the crime.

. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will: a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital commitment.

B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 539 | Page 541-542 TOP: Nursing Process: Outcomes Identification

Client Needs: Psychosocial Integrity 5. A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should: a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed self after explaining arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self. d. address needs of other patients in the dining room, then feed this patient.

B The patient 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) REF: Page 335-336 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 6. A patient with blindness related to conversion (functional neurological) disorder says, "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

B The patient mentions that the symptoms make people more interested. This indicates that the patient 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) REF: Page 325-326 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Psychosocial Integrity 11. A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will: a. assume roles and functions of other family members. b. demonstrate performance of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet personal needs.

B The patient 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) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Outcomes Identification

An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

B The patient's caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 546-547 TOP: Nursing Process: Planning

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

B Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 271-272 TOP: Nursing Process: Evaluation

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

B Various types of antidepressants may be helpful in somatic disorders directly by reducing depressive symptoms and hence somatic responses, but also indirectly by affecting nerve circuits that affect not only mood, but fatigue, pain perception, GI distress, and other somatic symptoms. Patients may benefit from short-term use of anti-anxiety 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) REF: Page 335-336 TOP: Nursing Process: Planning

Arrange the events in the development of forensic nursing in the proper sequence from the earliest to the most recent. A. Official recognition of forensic medicine as a specialty area B. Formation of International Association of Forensic Nurses (IAFN) C. Formal definition of the term "forensic nursing" by IAFN D.Development of the Scope and Standards of Forensic Nursing

B, A, D, C In the year 1992, IAFN was formed with 74 nurses. In 1995, the American Nursing Association (ANA) officially recognized forensic nursing as a specialty practice area. ANA and IAFN combined their efforts to develop the Scope and Standards of Forensic Nursing in 1997. In 2006, IAFN defined forensic nursing as "the application of nursing science to public or legal proceedings" and "the application of the forensic aspects of health care combined with the bio-psycho-social education of the registered nurse in the scientific investigation and treatment of trauma and/or death of victims and perpetrators of abuse, violence, criminal activity, and traumatic accidents."

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 risks associated with cyberbullying. 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.

B, C, D Education and awareness-based approaches have a chance of effectively reducing harmful online 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.

Which assessment questions would be most appropriate for the nurse to ask a patient with possible obsessive-compulsive disorder? Select all that apply. a."Are there certain social situations that cause you to feel especially uncomfortable?" b."Are there others in your family who must do things in a certain way to feel comfortable?" c."Have you been a victim of a crime or seen someone badly injured or killed?" d."Is it difficult to keep certain thoughts out of your awareness?" e."Do you do certain things over and over again?"

B, D, E The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with suspected posttraumatic stress disorder or with suspected social phobia. See relationship to audience response question.

Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 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 by proxy 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 patient frequently during visiting hours.

B, D, E Factitious disorder by proxy is a rare 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) REF: Page 337-338 TOP: Nursing Process: Implementation

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

B, D, E Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It's important for the nurse to use current terminology. Please don't use the R-word. It is extremely offensive.

Ms. Wong, aged 52 years, comes to the emergency room with severe anxiety. She was raised in China but immigrated to the United States at age 40 years. She was recently fired from her job because of a major error in the accounting department that she managed. Ms. Wong's aged parents live with her. Ms. Wong states, "I am a failure." Which of the following statements may accurately assess the basis for Ms. Wong's anxiety and feelings of failure? A. Ms. Wong may feel that she has let herself down since she did not achieve her personal goals in the workplace. B. Ms. Wong may feel that she has shamed the family by being fired and may no longer be able to provide for them. C. Ms. Wong may feel personally inadequate since she failed in her quest for independence and self-reliance. D. Ms. Wong may be feeling anxiety because in her family's traditions her failure may result in a changed fate.

B. Eastern tradition, such as in China, where Ms. Wong is from, sees the family as the basis for one's identity, and family interdependence as the norm. The views expressed in options a and c demonstrate Western tradition where self-reliance, individuality, and autonomy are highly valued. In the Eastern view one is born into an unchangeable fate.

A client reporting gastric pain, tells the nurse, "I think my symptoms started when a neighbor cast a spell on me." The assessment the nurse can make is that the client A. has a major mental illness. B. is expressing a culture-bound illness. C. requires hospitalization to protect the neighbor. D. will probably not respond to Western medical treatment.

B. Many culture-bound illnesses, such as ghost illness, or hwa byung, seem exotic or irrational to American nurses. Many of these illnesses cannot be understood within a Western medicine framework. Their causes, manifestations, and treatments do not make sense to nurses whose understanding is limited to a Western perspective on disease and illness.

Data concerning client age, sex, education, and income should be the focus of an assessment in order to best understand cultural issues related to A. health practices. B. power and control. C. psychological stability. D. assimilation and conformity.

B. Power and control are often products of culturally determined beliefs about who should hold power. In many cultures the elderly are venerated. In other cultures women are virtually powerless. For some cultures, higher education equates with power.

Josefina Juarez, aged 36 years, comes to the mental health clinic where you work after being referred by her primary care provider. Josefina came to live in the United States from Brazil 5 years ago. She is now a single mother to 6 children, ages 2 to 15, following the death of her husband last year. During the initial intake assessment, Josefina tells you her problem is that she has headaches and backaches "almost every day" and "can't sleep at night." She shakes her head no and looks away when asked about anxiety or depression and states she does not know why she was referred to the mental health clinic. You recognize that Josefina may be exhibiting: A. regression. B. somatization. C. enculturation. D. assimilation.

B. Somatization is described as experiencing and expressing emotional or psychological distress as physical symptoms. Regression is a defense mechanism meaning to begin to function at a lower or previous level of functioning. Enculturation refers to how cultural beliefs, practices, and norms are communicated to its members. Assimilation refers to a situation in which immigrants adapt to and absorb the practices and beliefs of a new culture until these customs are more natural than the ones they learned in their homeland.

The Eastern world view can be identified by the belief that A. one's identity is found in individuality. B. holds responsibility to family as central. C. time waits for no one. D. disease is a lack of harmony with the environment.

B. The Eastern traditional world view is sociocentric. Individuals experience their selfhood and their lives as part of an interdependent web of relationships and expectations.

You are caring for Maria, a patient who states that she has "ghost sickness." Which is the appropriate nursing response? a. "I have no idea what 'ghost sickness' is." b. "How does 'ghost sickness' make you feel?" c. "'Ghost sickness' is not listed in the manual of psychiatric disorders." d. "Let's talk about why you believe in evil spirits?"

B. "How does 'ghost sickness' make you feel?"

Janice is a nurse whose husband is in rehab for alcohol use disorder. While attending a family group, Janice makes several statements about their relationship. Which of these statements would suggest Janice is exhibiting codependent behavior? (Select all that apply) A. "My husband has to accept responsibility for his behavior and the consequences of his drinking." B. "I know I shouldn't go out drinking with him, but I'm afraid he'll leave me if I don't." C. "May father was the same way and i learned its better just to keep your mouth shut so you don't get hit." D. "If he didn't have me monitoring his every move he'd probably be dead already." E. "I need to make sure I'm protecting myself and my children."

B. "I know I shouldn't go out drinking with him, but I'm afraid he'll leave me if I don't." C. "May father was the same way and i learned its better just to keep your mouth shut so you don't get hit." D. "If he didn't have me monitoring his every move he'd probably be dead already." Feedback 2: People-pleasing, fear of abandonment, and neediness, as evidenced in this statement, are all consistent with codependency. Feedback 3: The sense of helplessness and a history of abuse or neglect as a child are consistent with codependency. Feedback 4: This statement suggests an unrealistic need to be in control and may also suggest that Janice's self-worth is rooted in her need to be needed. Both of these statements are evidence of codependency

The duration of most of the panic reactions from cannabis is about: A. 1 hour B. 3-6 hours C. a day D. a week

B. 3-6 hours

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down a hallway. B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia. C. A client in a day treatment program who says he is becoming more anxious during group therapy. D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months.

B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia.

Who provides care to a patient who is in jail and diagnosed with a mental illness? A. The criminal profiler B. The correctional nurse C. The hostage negotiator D. The forensic nurse generalist

B. A correctional nurse provides health care to people who are charged under the criminal justice system. A criminal profiler collects the data available and formulates a hypothesis. A hostage negotiator provides training in communication skills to law enforcement officers. A forensic nurse generalist assesses victims of violence, collects evidence, and keeps proper documentation.

A registered nurse is called to testify as a fact witness in a trial. As a fact witness, to what can the nurse testify? A. What was witnessed B. What was witnessed or performed personally C. What was documented by other health care workers D. What the nurse was told by a third party

B. A fact witness testifies regarding what was personally seen or heard, performed, or documented regarding a patient's care and testifies to first-hand experience only. Fact witnesses cannot testify to what was told to them by another person, only what they witnessed themselves. The nurse may testify only to documentation that he or she performed.

An advocate suspects that the defendant is legally insane and approaches the forensic nurse to act as a consultant in a second-degree murder case. What appropriate action should the nurse take in court? A. The nurse should avoid acting as an advocate for the patient and family. B. The nurse should guide the advocate during the cross-examination of the defendant. C. The nurse should resist giving information about medication of the defendant. D. The nurse should suggest confining the defendant in jail.

B. A forensic nurse can also act as a consultant in the case. The consultant nurse should guide the advocate in cross-examination by listening to the defendant's and witness's testimony. The nurse should also give information about the defendant's mental illness and assist in the preparation for trial. The nurse should act as an advocate to the patient and family and help in proving the mental illness of the patient. The nurse should give the information about the medication and treatment options for the defendant. Confinement or imprisonment of defendants can make them aggressive or depressed and can cause chronic mental illness.

A defendant was recognized as legally insane by the court and was sent to a psychiatric facility. The forensic nurse is assigned to assess the defendant and to conduct group activities. Which role of forensic psychiatric nursing does the nurse assume? A. Fact witness B. Competency evaluator C. Forensic examiner D. Hostage negotiator

B. A forensic nurse should play different roles and functions. It is the role of the competency evaluator to regularly assess the mental condition of a defendant who is mentally ill. The nurse should plan a treatment plan and conduct one-on-one and group actives for the defendant. This helps to stabilize the defendant and give effective treatment for the mental illness. The role of fact witness is to give the statement in the court and to testify about the initial condition and treatment given to the victim. The role of forensic examiner is to observe the behavior of the defendant in the courtroom, jail, and at the site of the incident. This helps to identify and state whether the defendant is legally insane or sane. The role of the hostage negotiator is to address the mental state of the perpetrator before, during, and after the hostage crisis.

Which client and family teaching is most important regarding the cause of substance addiction? A. an individual's social and cultural environment can be implicated in the cause of substance addiction. B. Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction. C. Evidence of a genetic link accounts for most cases of substance addiction. D. Reinforcing properties of the substance encourages progression from use to addiction.

B. Biological, psychological, and sociocultural factors can all be implicated in the cause of substance addiction. The development of substance addiction is multifactorial and may include biological, psychological, and/or sociological factors

Which of the following medications is the physician most likely to order for a client experiencing alcohol withdrawal syndrome? A. Haloperidol (Haldol) B. Chlordiazepoxide (Librium) C. Methadone (Dolophine) D. Phenytoin (Dilantin)

B. Chlordiazepoxide (Librium)

During a court hearing, a schizophrenic defendant says, "I know I should not have killed the person. I don't know what happened to me at that moment. I just could not resist myself." What is the most appropriate legal test of sanity related to the act? A. McNaughton's rules B. Irresistible impulse C. Guilty but mentally ill D. Competence to proceed

B. The defendant knew that it was wrong to kill the person, but could not control the behavior because of the schizophrenic mental illness. The defendant is therefore, not guilty as per the "irresistible impulse" test for legal sanity. According to McNaughton rules, in order to be considered legally sane, the accused with a mental illness must understand the nature of the act and be able to judge whether the act is right or wrong. Sometimes, the accused may be judged guilty but mentally ill. In such cases, the accused is sent to a correctional facility for treatment and subjected to the facility's parole decisions. Competence to proceed is not a test of the legal sanity at the time of the act. It is a test done during a hearing to judge if the defendant is of sound mind and competence at the time of the trial. It determines whether the defendant will be able to assist the attorney and understand the legal proceedings.

Dan, who has been admitted to the alcohol rehabilitation unit after being fired for drinking on the job, states to the nurse, "I don't have a problem with alcohol. I can handle my booze better than anyone I know. My boss is a jerk! I haven't missed any more days than my coworkers." The nurse's best response is: A. Maybe your boss is mistaken, Dan. B. You are here because your drinking was interfering with your work, Dan C. Get real, Dan! Youre a boozer and you know it! D. Why do you think your boss sent you here, Dan?

B. You are here because your drinking was interfering with your work, Dan

Adoption studies of alcoholics' children have uncovered: A. no genetic predisposition to alcoholism B. a significant genetic component to alcoholism C. a significant environmental component to alcoholism D. a significant genetic-environment interaction in the etiology of alcoholism.

B. a significant genetic component to alcoholism

Which would the nurse consider a priority intervention when planning care for a medically unstable client diagnosed with alcohol use disorder? A. simplifying the environment B. addressing physical needs C. providing opportunities for success experiences D. establishing a trusting interpersonal relationship

B. addressing physical needs Physical problems must be addressed prior to meeting any psychosocial needs of a client who is medically unstable. According to Maslow's hierarchy of needs, physiological needs should be prioritized over all other needs.

A client who is unable to control binge drinking requires increased amounts of alcohol to achieve the same level of intoxication. The client is experiencing marital strife and legal problems. The client's behaviors meet the criteria for which DSM-5 diagnostic category? A. dual diagnosis B. alcohol use disorder C. neurocognitive disorder D. Alcohol intoxication

B. alcohol use disorder This client has developed tolerance, cannot control alcohol intake, and has continued use despite persistent problems related to drinking. These symptoms meet the criteria for the diagnosis of alcohol use disorder in the DSM-5.

A person's hands and eyelids are shaking, and that person is experiencing visual and tactile hallucinations. Of the following, that person is most likely experiencing: A. Korsakoff's Syndrome B. delirium tremens C. narcotic attraction D. cannabis toxicity

B. delirium tremens

The nurse is assessing a client who is a substance abuser. the client states, "I use every day, but it rarely interferes with my work.". The nurse determines that the client is using which defense mechanism? A. projection B. denial C. reaction formation D. displacement

B. denial Denial is characterized by avoidance of disagreeable realities and unconscious refusal to acknowledge a thought, feeling, need or desire. By stating that alcohol use rarely interferes with his or her work, the client is denying a substance abuse problem.

Which primary factor is critical in maintaining abstinence for the client diagnosed with alcohol use disorder? A. attendance at Alcoholics Anonymous (AA) meetings B. personal commitment to change C. Family involvement D. compliance with pharmacological therapy

B. personal commitment to change The first step in the recovery process necessitates that the client accept ownership of the problem and establish a behavioral change commitment to continued abstinence

Pamela has sought treatment for ongoing substance use disorder. She asks the nurse what treatment options are available to help her combat this problem. Which of these options would be accurate for the nurse to include in patient education? (Select all that apply) A. ECT B. self-help groups C. deterrent therapy D. Substitution pharmacotherapy E. Vitamin supplements

B. self-help groups C. deterrent therapy D. Substitution pharmacotherapy Feedback 2: self-help groups such as Alcoholics Anonymous are commonly recommended as a treatment option for substance use disorders. Feedback 3: Deterrent therapy, such as Antabuse to deter alcohol use, is a recognized option for some substance use disorders. Feedback 4: Substitution therapy, such as methadone for heroin users, is a recognized option for some substance use disorders.

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks." B. "The therapists will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences." ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

B: Classical psychoanalysis : - many sessions, months to years. - focuses on past relationships to identify the cause of the anxiety disorder. - assesses unconscious thoughts and feelings. ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

When alprazolam (Xanax) is prescribed for a patient who experiences acute anxiety, health teaching should include instructions to: a.report drowsiness. b.eat a tyramine-free diet. c.avoid alcoholic beverages. d.adjust dose and frequency based on anxiety level.

C Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected effect and needs to be reported only if it is excessive. Patients should be taught not to deviate from the prescribed dose and schedule for administration.

A patient tells a nurse, "My new friend is the most perfect person one could imagine: kind, considerate, and good-looking. I can't find a single flaw." This patient is demonstrating: a.denial. b.projection. c.idealization. d.compensation.

C Idealization is an unconscious process that occurs when the individual attributes exaggerated positive qualities to another. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety related to __________ as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? a.feelings of responsibility for the health of family members b.approval-seeking behavior from friends and family c.persistent thoughts about bacteria, germs, and dirt d.needs to avoid interactions with others

C Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior. See relationship to audience response question.

Two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? a.Introjection b.Conversion c.Projection d.Splitting

C Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others. Conversion involves the unconscious transformation of anxiety into a physical symptom. Introjection involves intense, unconscious identification with another person. Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? a."I don't know why I do mean things." b."I have always had poor impulse control." c."That person should not have provoked me." d."I'm really a coward who is afraid of being hurt."

C Rationalization consists of justifying one's unacceptable behavior by developing explanations that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse is not his or her fault; it would not have occurred except for the provocation by the other person. The distracters indicate some measure of acceptance of responsibility for the behavior.

A person diagnosed with bipolar disorder ran out of money, did not refill a lithium prescription, and then relapsed. After assaulting several people in the community, this person was convicted and sentenced. Prior to parole, which outcome has priority for the correctional nurse to achieve? The person: A. agrees in writing to continue lithium therapy. B. is reestablished on an appropriate dose of lithium. C. lists community resources for prescription assistance. D. agrees to a follow-up appointment in an outpatient clinic.

C To increase medication adherence, reduce the risk of relapse, and prevent further criminal activity due to mental illness, the person's awareness of community resources for medication refills and medication-related services is the most important outcome. Agreeing to take lithium, being reestablished on medication in the jail, and agreeing to follow-up mental health care are important, but none of these will address the primary reason for the criminal behavior: the relapse caused by inability to access medication in the community.

A nurse testifies about care provided to a patient in the 8 hours before a successful suicide. The nurse responds to questions about observations regarding the patient's behavior as well as interventions performed and documented during the shift. In what capacity was this nurse testifying? a. Forensic nurse examiner b. Expert witness c. Fact witness d. Consultant

C A fact witness testifies regarding first-hand experience only; that is, the facts the witness possesses because of personal experience with the situation under review. Forensic nurse examiners conduct court-ordered examinations and provide written reports and court testimony regarding the findings of the examinations, but they do not give direct patient care. Consultants are neutral experts who educate or advise the court or its officers on technical matters such as standards of nursing care. An expert witness shares professional expertise about the defendant or elements of the crime and testifies on behalf of the prosecution or defendant.

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: a. promote integration of self-concept. b. provide inpatient treatment for the child. c. reduce loneliness and increase self-esteem. d. improve language and communication skills.

C Because of their disruptive behaviors, children with 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.

Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group b. A mental health center c. A women's shelter d. Vocational counseling

C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537 | Page 544 (Box 28-6) TOP: Nursing Process: Implementation

A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which medication will the information focus on? a. Paroxetine (Paxil) c. Methyphenidate (Ritalin) b. Imipramine (Tofranil) d. Carbamazepine (Tegretol)

C CNS stimulants are the drugs of choice for treating children with ADHD: Ritalin and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 274 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 21. A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient 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: a. marginally successful. b. minimally successful. c. partially successful. d. totally achieved.

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 patient resistance. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 333 | Page 337 TOP: Nursing Process: Evaluation

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4) TOP: Nursing Process: Implementation

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 543 TOP: Nursing Process: Implementation

A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

C Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266 (Table 14-6) | Page 268 (Box 14-3) TOP: Nursing Process: Implementation

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

C Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 538-539 TOP: Nursing Process: Assessment

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child: 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.

C Holding the hand of another person suggests relatedness. Usually, a child 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.

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has: a. complaints of abdominal pain. b. repeated middle ear infections. c. bruises on extremities. d. diarrhea.

C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

A psychiatric forensic nurse examiner was asked by a defendant's attorney to determine the defendant's legal sanity. What is the priority task of the nurse examiner? a. Determine if the defendant understands the charges and can assist the attorney with the defense. b. Complete a risk assessment to determine if the defendant is a danger to self or others. c. Reconstruct the defendant's mental state and motives at the time of the crime. d. Collect and compile evidence to determine whether a crime occurred.

C Legal sanity is determined for the specific time of the alleged crime, so reconstructing the defendant's mental state, motivation, thinking, and other elements of functioning at the time of the alleged crime is essential to making the determination. The defendant's ability to understand the charges and assist in his defense is pertinent to an evaluation of competency. Unless the court has specifically asked for a risk assessment (which would be unusual), the risk assessment is the responsibility of clinical staff caring for the patient, not the forensic nurse examiner. Police collect evidence about the crime, and the prosecutor compiles it. A forensic nurse examiner does not participate in evidence collection other than that related to the assessment of the patient's state of mind at the time of the alleged crime.

An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 532 | Page 535 | Page 537 (Box 28-4) TOP: Nursing Process: Assessment

An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with similar characteristics to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. Which action by the correctional nurse is most appropriate? A. Plan to meet with the inmate for debriefing after release from the required period of restraint. B. Support use of restraints as needed to control violent outbursts and assure the safety of all inmates. C. Contact a supervisor authorized to make an exception to the restraint policy and explain why an alternate response is needed. D. Confront the correctional officers who initiated the restraint, explain the inappropriateness of this action, and request the inmate's release

C Nurses have advocacy responsibilities, regardless of the setting. The optimum outcome in this situation would be to minimize the duration of the restraint episode. The inmate and others are at risk of injury until the inmate is calm. The restraints will likely worsen and extend the inmate's distress and agitation. Supporting the use of restraints ignores the need of select inmates for alternate responses that do not paradoxically worsen the situation instead of help it. Meeting with the patient to calm her after her release would be the second most helpful response, but it does not shorten the duration of the patient's restraint. Confronting the officers is unlikely to be successful, since they are following proper procedures; accusing them of improper actions will likely increase defensiveness rather than expedite the inmate's release from restraint.

A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

C Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 16. A patient 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." It is important for the nurse to assess: a. mood. b. cognitive style. c. secondary gains. d. identity and memory.

C Secondary gains should be assessed. The patient's dependency needs may be met through care from the family. When secondary gains are prominent, the patient 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 patient's diagnosis has been established. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 331-333 (Table 17-3) | Page 335 (Table 17-4) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 7. To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority: a. explain the pathophysiology of symptoms. b. help these patients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d. investigate each physical symptom as it is reported.

C Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in the patient 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 patient would express feelings, including anger if it is present. Once physical symptoms are investigated, they do not need to be reinvestigated each time the patient reports them. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 333-335 (Table 17-4) TOP: Nursing Process: Implementation

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

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 patient'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) REF: Page 334-335 TOP: Nursing Process: Planning

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 268 (Box 14-3) TOP: Nursing Process: Implementation

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building b. Acute battering c. Honeymoon d. Stabilization

C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 534 TOP: Nursing Process: Assessment

The correctional nurse assesses a new prisoner beginning incarceration after committing a sex crime. The prisoner speaks in a low voice and tearfully tells the nurse, "My life might as well be over. There is no hope I will ever fit into society after I get out of prison. My family disowned me." Select the nurse's priority action. A. Advise guards to place the inmate in solitary confinement. B. Offer to contact the inmate's family to convey these feelings of remorse. C. Alert the guards of the risk for suicide and implement suicide precautions. D. Meet with the inmate weekly to discuss these feelings and explore coping strategies.

C The inmate is experiencing significant shame and self-loathing, facing many significant losses (freedom, status in the community, perhaps his career), separated from his support system, and evidences hopelessness. These all suggest a significant risk of suicide. The priority response would be to alert the guards of the inmate's risk to self and implement suicide precautions. Safety is the primary issue; none of the other options is appropriate relative to suicide prevention.

A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

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

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.

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?"

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.

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.

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.

Which statement about the practice of correctional nursing is accurate? a. Because the majority of inmates are younger than 40 years of age, most have lower rates of chronic illnesses than the general population. b. Correctional nurses work primarily with medically ill persons rather than persons with psychiatric or substance abuse disorders. c. More persons diagnosed with mental illness receive treatment services in prisons than in inpatient psychiatric facilities. d. Correctional nurses commonly provide holistic and comprehensive care for the incarcerated population.

C When compared to the rates in the general population (11% of whom have a mental health problem, with approximately 55,000 individuals hospitalized at an inpatient psychiatric hospital on any given day), correctional facilities carry a disproportionate share of the burden for the provision of mental health services. Rates of chronic illness are higher among inmates than in the general population due to factors such as higher rates of poverty, lower educational status, higher rates of trauma, institutional living when incarcerated, reduced access to health care, poor health habits, and higher rates of high-risk behaviors such as IV drug abuse. Correctional settings provide adequate care of inmates, but it is rarely holistic or comprehensive.

The forensic psychiatric nurse is teaching newly recruited nurses about the skills required to become a forensic psychiatric nurse. What skills recalled by a new nurse indicate a need for further teaching concerning the role of forensic psychiatric nurse? Select all that apply. A. Skill in interpersonal communications B. Knowledgeof the criminal justice system C. Ability to judge other's values and motivations D. Inclination to work within traditional boundaries E. Ability to thrive in stimulating intellectual environment

C, D Forensic psychiatric nurses should not be judgmental about other's values or motivations. They should view everything in an objective manner and should be able to accept other's values and motivations. They should enjoy pushing the limits of traditional boundaries. They may often be viewed with skepticism because nursing places a lot of value on tradition. Forensic psychiatric nurses should be able to deal with such responses with professionalism. They need skills in interpersonal communications to be able adequately interact with people in other disciplines. They need to have an understanding of the criminal justice system. This helps them to assess and care for victims and defendants of criminal cases, act as witnesses, and testify in court during criminal cases. They should be able to thrive in a stimulating intellectual environment as they apply clinical skills to complex legal issues.

Which experiences are most likely to precipitate posttraumatic 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.

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 individuals 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.

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.

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.

Which characteristic is a requirement to testify as a forensic nurse expert witness? Select all that apply. A. Possesses excellent interpersonal communication skills B. Earned a law degree four years ago and continues to practice defense law C. Holds an advanced academic degree and certifications in forensic nursing D. Has six years of experience with a multidisciplinary forensic team at a major urban hospital E. Has published three journal articles related to evidence collection techniques that meet legal standards

C, D, E The criteria for establishing expertise to testify as a forensic nurse include academic preparation, professional training, practical working experience in the field, involvement in professional organizations, and research and publications in the area of expertise. A law degree is not necessary, and while communication skills are important, excellent skills are not necessary.

The psychiatric mental health nurse working with depressed clients of the Eastern culture must realize that a useful outcome criterion might be if client reports A. increased somatic expressions of distress. B. disruption of energy balance. C. appeasement of the spirits. D. increased anxiety.

C. Appeasement of spirits might be a viable outcome criterion if the client believes the illness was caused by angry spirits. In each of the other options useful outcomes would be decreased somatic symptoms, reinstatement of energy balance, and decreased anxiety.

Which of the following best explains the concept of cultural competence? A. Nurses have enough knowledge about different cultures to be assured they are delivering culturally sensitive care. B. Nurses are able to educate their patients from other cultures appropriately about the cultural norms of the United States. C. Nurses adjust their own practices to meet their patients' cultural preferences, beliefs, and practices. D. Nurses must take continuing education classes on culture in the process of becoming culturally competent.

C. Cultural competence means that nurses adjust and conform to their patients' cultural needs, beliefs, practices, and preferences rather than their own. This option does not describe cultural competence. Although nurses are continually learning regarding culture, it is a career-long process. The goal is not to educate patients about our own culture but rather to adjust to their cultural preferences. Although nurses may take continuing education regarding culture, this does not describe the term cultural competence. The other options do not describe cultural competence.

A peer asks you to help him differentiate between culture and ethnicity for clarification. Which statement by the peer would acknowledge that you had appropriately helped him clarify the difference between the two terms? A. "So, ethnicity refers to having the same life goals whereas culture refers to race." B. "So, ethnicity refers to norms within a culture, and culture refers to shared likes and dislikes." C. "So, ethnicity refers to shared history and heritage, whereas culture refers to sharing the same beliefs and values." D. "So, ethnicity refers to race, and culture refers to having the same worldview."

C. Ethnicity is sharing a common history and heritage. Culture comprises the shared beliefs, values, and practices that guide a group's members in patterned ways of thinking and acting. The other options are all incorrect definitions of ethnicity and culture.

Clients of another culture are at greatest risk for misdiagnosis of a psychiatric problem because of A. biased assessment tools. B. insensitive practitioners. C. insensitive interviewing techniques. D. lack of the availability of cultural translators.

C. Inaccurate information or insufficient information may be obtained if the interviewer is not culturally sensitive. Only when assessment data are accurate can effective treatment be planned.

When members of a group are introduced to the culture's worldview, beliefs, values, and practices, it is called A. acculturation. B. ethnocentrism. C. enculturation. D. cultural encounters.

C. Members of a group are introduced to the culture's worldview, beliefs, values, and practices in a process called enculturation. Ethnocentrism is the universal tendency of humans to think that their way of thinking and behaving is the only correct and natural way. Acculturation is learning the beliefs, values, and practices of a new cultural setting, which sometimes takes several generations. Cultural encounters occur when members of varying cultures meet and interact.

Which source of healing might be most satisfactory to a client who believes his illness is caused by spiritual forces? A. Acupuncture B. Dietary change C. Cleansings D. Herbal medicine

C. Rituals, cleansings, prayer, and even witchcraft may be the treatment expectation of a client who believes his illness is caused by spiritual forces.

Exclusive use of Western psychological theories by nurses making client assessments will result in A. a high level of care for all clients. B. standardization of nomenclature for psychiatric disorders. C. inadequate assessment of clients of diverse cultures. D. greater ease in selecting appropriate treatment interventions.

C. Unless clients have faith in a particular healing modality, the treatment may not be effective. When nurses make assessments on the basis of Western theories, treatments consistent with those assessments follow. Clients of other cultures may find the treatment modalities unacceptable or not useful. Treatments consistent with the client's cultural beliefs as to what will provide a cure are better.

A client who is going through alcohol detoxification states, "I see bugs crawling on the wall." Which is the best nursing response? A. "I'll remove the bugs from the wall." B. "You are confused because of your alcoholism." C. "There are no bugs on the wall. I'll stay with you until you feel less anxious." D. "You do not see any bugs on the wall."

C. "There are no bugs on the wall. I'll stay with you until you feel less anxious." This response presents objective reality and may help decrease the client's anxiety by the nurse's therapeutic offering of self.

A nurse in an acute mental health facility is caring for a client who has a severe mental illness and soon will be ready for discharge but still requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following should the nurse suggest as appropriate follow-up care? A. Receiving daily care from a home health aide. B. Having a weekly visit from a nurse case worker. C. Attending a partial hospitalization program. D. Visiting a community mental health center on a daily basis.

C. Attending a partial hospitalization program.

When a psychiatric nurse is issued a subpoena to appear in court as a fact witness, it is understood he or she will testify A. To give an opinion about how care was provided by a colleague B. To provide expertise as a psychiatric nurse C. To what he or she saw or heard regarding a patient's care D. To the character of a co-worker who is being sued for negligence

C. By license, any nurse can be subpoenaed to testify as a fact witness. A fact witness testifies regarding what was seen, heard, performed, or documented regarding a patient's care. A fact witness testifies about first-hand experience only. Giving an opinion about how care was provided by a colleague, providing expertise as a psychiatric nurse, or testifying to the character of a co-worker who is being sued for negligence do not accurately describe the function of a fact witness.

A person kidnapped a movie star, but was later captured and charged. Which assessment finding regarding this kidnapper is most likely to support use of the legal insanity defense? At the time of the crime, the kidnapper demonstrated: A. Obsessions B. Perseveration C. Delusional thinking D. Psychomotor retardation

C. Delusional thinking is an indicator of psychosis, or loss of touch with reality. In most states, the presence of a major mental disorder (usually referring to those that cause psychoses: delusions, hallucinations, and disorganized thought) is a prerequisite for a finding of legal insanity. Obsessions, perseveration, and psychomotor retardation show signs and symptoms associated with mental illness, but are not associated with psychosis.

A client with chronic alcoholism says to the nurse, "I'm tired of using and I want to stop. Is there a medication that can help me maintain sobriety?" About which medication would the nurse provide information? A. carbamazepine (Tegretol) B. clonidine (Catapres) C. Disulfiram (Antabuse) D. folic acid (Folvite)

C. Disulfiram (Antabuse) Disulfiram is used as a deterrent to drinking. Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can cause varying degrees of discomfort. It can even result in death if blood alcohol levels are high enough. It is important that the client understands that all alcohol, oral or topical, and medications that contain alcohol are strictly prohibited when taking this drug.

Which skill is central to the role of all forensic nurses? A. Creating therapeutic nurse-patient relationships with incompetent criminals B. Helping court-appointed lawyers with the suspect's testimony C. Evidence collection that preserves the integrity of the evidence D. Acting as a correctional mental health nurse

C. Evidence collection is central to the role of all forensic nurses.

There are a number of criminal cases filed against a person. After assessing the person in relation to a particular criminal case, the nurse reports that the defendant is incompetent to proceed due to a mental illness resulting from a developmental disability. What is the most likely outcome following this report? A. The defendant is judged guilty and prosecuted. B. The defendant is released without any charges. C. The defendant is sent for treatment of mental illness. D. The defendant is declared incompetent in all cases.

C. If the defendant is reported to be incompetent to proceed in a legal case, the person is sent for treatment. The case can be resumed when the defendant is found to be legally competent. Since the legal proceedings are halted midway, the person can neither be proven guilty and prosecuted nor be released without any charge. Even if the person is declared incompetent to proceed in a particular case, it does not mean he or she can be declared incompetent in all cases. Competence to proceed determines the present mental capacity. Incompetence to proceed during one appearance before the court for one case does not mean the person with be incompetent during a later appearance before the court or for another case. Competence is determined each time the person goes to court.

A psychiatric forensic nurse would not likely assume the role of a(n) A. Behavioral sciences expert B. Expert witness C.Advocate for a hostage perpetrator D. Consultant to a hostage negotiation team

C. In the late 1970s, the Federal Bureau of Investigation began expanding the structure of hostage negotiation teams by recommending the use of consultants who could address the mental state of the perpetrator and recommend appropriate negotiation strategies. When functioning as a behavioral sciences expert, the role of the psychiatric forensic nurse differs markedly from that of the community mental health nurse. In the former role, the psychiatric forensic nurse is not an advocate for the perpetrator, but rather for the process of hostage negotiation.

Julio is a 31-year-old patient who comes to your mental health out- patient clinic. Which of the following would alert you to the potential for somatization? a. Julio states, "I have been feeling sad for weeks." b. Julio shows you bottles of medication he has been prescribed for anxiety. c. Julio presents with concerns involving headaches, dizziness, and fatigue. d. Julio states, "I have been sleeping all the time."

C. Julio presents with concerns involving headaches, dizziness, and fatigue.

A much-needed role for forensic nurses to assume is A. Prison milieu management B. Medication administration C. Liaison with parole officers D. Primary prevention programs

C. Smoother transitions from prison to parole are desirable. Continuity of care is essential to maintain the individual outside the structure of the prison system. Collaboration between the prison system and the parole system would benefit the patient.

A nurse is reinforcing teaching with a female client who has bipolar disorder about her new prescription for lithium carbonate (Lithobid). Which of the following is appropriate for the nurse to include? (Select all that apply) A. Expect amenorrhea as an adverse effect of this medication B. Take an antidepressant with lithium during phases of mania C. Take this medication with food or a glass of milk D. Avoid pregnancy while taking this medication E. Have thyroid function tests prior to lithium therapy

C. Take this medication with food or glass of milk D. Avoid pregnancy while taking this medication E. Have thyroid function tests prior to lithium therapy

A client is diagnosed with stimulant use disorder; cocaine and antisocial personality disorder. The client eagerly participates in therapy and becomes charming and ingratiating to the primary nurse. Which best describes these client behaviors? A. The client has not completed the cocaine withdrawal process B. The client is probably hiding something C. The client is exhibiting characteristics of antisocial personality disorder D. The client is exhibiting symptoms of cocaine dependence.

C. The client is exhibiting characteristics of antisocial personality disorder Charming and ingratiating behaviors are characteristic traits of clients diagnosed with antisocial personality disorder.

The forensic psychiatric nurse is assigned the care of a victim of physical violence. What is the most appropriate role of the forensic psychiatric nurse in this situation? A. Check if the statements made by the victim are genuine. B. Decide if the perpetrator is actually guilty of the crime. C. Use medical-surgical knowledge to care for the victim. D. Testify in the court on behalf of the victim in their care.

C. The forensic psychiatric nurse remains objective and uses medical-surgical knowledge to care for the victim. It is not the role of the nurse to check if the statement made by the victim is genuine or to decide if the perpetrator is actually guilty. The nurse cannot be judgmental. The law decides whether the victim's statement is genuine and whether the perpetrator is guilty. The nurse may need to testify in court to support the legal proceedings. However, the nurse should not testify on behalf of the victim just because the victim has been in the nurse's care. All statements made by the nurse in the court should be objective and based on the available evidence.

Students were asked to do a role play of hostage nurse, police officer, and perpetrator after a lecture on forensic nursing. Which action by the student nurse playing the role of the hostage nurse indicates effective learning? A. The hostage nurse avoids making decisions during stressful conditions. B. The hostage nurse remains silent while interacting with a perpetrator. C. The hostage nurse suggests negotiation techniques to police officers. D. The hostage nurse assists the police in collecting evidence at the crime scene.

C. The hostage nurse should suggest negotiation techniques to the police officers. This helps in effectively interrogating the perpetrator and collecting the evidence. The hostage nurse should make decisions effectively even in stressful conditions. This helps to effectively evaluate the mental status of the perpetrator. Proper assessment cannot be done if the nurse remains calm and silent while interacting with the perpetrator. The nurse should effectively interact with the perpetrator to determine the intentions behind the crime. The hostage nurse should not demand authority. It is the duty of the forensic nurse to help the law enforcement officers in collecting the evidence of the crime.

In a popular approach to treatment of alcoholism, clients keep track of their own drinking behavior. They are then taught coping strategies and learn to set limits. This is called: A. alcoholics anonymous B. forced abstinence C. behavioral self-control training D. aversive conditioning

C. behavioral self-control training

Symptoms of alcohol withdrawal include: A. euphoria, hyperactivity and insomnia B. depression, suicidal ideation, and hypersomnia C. diaphoresis, N/V, and tremors D. unsteady gait, nystagmus, and profound disorientation

C. diaphoresis, N/V, and tremors

This dangerous drug has qualities of a stimulant and a hallucinogen. It produces undesired immediate effects, including confusion, depression anxiety, sleep difficulties and paranoia: It is called: A. methamphetamine B. psilocybin C. ecstasy D. mescaline

C. esctasy

The use of methadone in drug maintenance programs is controversial because methadone: A. use increases the risk of contracting AIDS B. costs over $50/day per person treated C. produces withdrawal more difficult than from heroin D. needs to be taken several times per day in a rigid schedule

C. produces withdrawal more difficult than from heroin

An impaired nurse is admitted to an inpatient substance abuse treatment facility. Which applies to this situation? A. the nurse must relinquish his driver's license to the office of motor vehicles. B. The nurse is mandated to comply with treatment and prescribed therapies. C. the nurse is not mandated to meet specific requirements, because all civil rights are ensured. D. The nurse must relinquish his registered nurse (RN) license to the state board of nursing.

C. the nurse is not mandated to meet specific requirements, because all civil rights are ensured. Although some variations occur from state to state, currently psychiatric clients maintain all of their civil rights. This nurse is not mandated by law to meet specific requirements, because all civil rights are ensured.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the highest priority to report to the provider? A. "My mother has diabetes that is controlled by her diet." B. "My mother recently completed a course of prednisone for acute bronchitis." C. "My mother received her flu vaccine last month." D. "My mother is currently on furosemide for her congestive heart failure."

D

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

D

For a patient experiencing panic, which nursing intervention should be implemented first? a.Teach relaxation techniques. b.Administer an anxiolytic medication. c.Prepare to implement physical controls. d.Provide calm, brief, directive communication.

D Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering anxiolytic medication should be considered if providing calm, brief, directive communication is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out the intervention of preparing for physical control until other less-restrictive measures are proven ineffective.

A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of: a.flooding. b.desensitization. c.relaxation technique. d.cognitive restructuring.

D Cognitive restructuring involves the patient in testing automatic thoughts and drawing new conclusions. Desensitization involves graduated exposure to a feared object. Relaxation training teaches the patient to produce the opposite of the stress response. Flooding exposes the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety response.

A person who feels unattractive repeatedly says, "Although I'm not beautiful, I am smart." This is an example of: a.repression. b.devaluation. c.identification. d.compensation.

D Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for imitation of mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or others.

A patient undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using? a.Displacement c.Projection b.Regression d.Denial

D Denial is an unconscious blocking of threatening or painful information or feelings. Regression involves using behaviors appropriate at an earlier stage of psychosexual development. Displacement shifts feelings to a more neutral person or object. Projection attributes one's own unacceptable thoughts or feelings to another.

A student says, "Before taking a test, I feel very alert and a little restless." The nurse can correctly assess the student's experience as: a.culturally influenced. b.displacement. c.trait anxiety. d.mild anxiety.

D Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because it promotes study and increases awareness of the nuances of questions. The incorrect responses have different symptoms. See relationship to audience response question.

An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with characteristics similar to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. The correctional nurse should anticipate that the inmate would react to restraint by: A. committing to counseling to reduce the incidence of flashbacks. B. becoming less likely to assault others during future flashbacks. C. gradually calming and returning from the flashback to reality. D. becoming more frightened, agitated, and combative.

D The correctional nurse recognizes that events occurring in the present reality are likely to be incorporated into a flashback, leading the inmate to become more frightened and desperate to escape. Even if no longer experiencing a flashback, persons will likely reexperience their original trauma if restrained, including the emotions experienced during that trauma, leading to increased fearfulness and resistance to the jail restraints. Restraints are not likely to calm the individual or reduce aggressiveness but instead increase the sense of helplessness and desperation.

A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 10. To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms: a. are generally chronic. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.

D At the unconscious level, the patient's primary gain from the symptoms is anxiety relief. Considering that the symptoms actually make the patient more psychologically comfortable and may also provide secondary gain, patients 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) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Planning

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child: a. has occasional toileting accidents. b. is unable to read children's books. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

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. The distracters are expected findings for a 3-year-old.

A guard tells an inmate diagnosed with schizophrenia to ask the desk officer for a mop and bucket, then get some water from the shower area and mop the kitchen and hall. The inmate does not comply. The guard becomes angry and cancels the inmate's recreation time. Which action by the correctional nurse is most appropriate? a. Document the inmate's response as indicative of resistance and psychopathology. b. Do not intervene. Intervention is not part of a correctional nurse's scope of practice. c. Confer with the prison psychiatrist regarding reevaluation of this inmate's antipsychotic medication regime. d. Explain to the guard that this inmate has difficulty following multiple instructions. Suggest stating one idea at a time.

D Correctional nurses, like most direct-care nurses outside of corrections, have a professional responsibility to advocate for inmates regarding needed care. A psychiatric nurse would have an understanding of schizophrenia and recognize that the inmate's ability to process multistep instructions was impaired. Advocacy for the inmate is evident by educating the guard so he would not misperceive the reason the inmate did not respond. Documentation is needed for all nursing activities. Involving the psychiatrist might be of some value but is at best a passive form of advocacy, and again, as worded here, suggests that the nurse does not understand how schizophrenia contributed to the inmate's not responding to complex instructions.

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 540-541 | Page 548-549 (Nursing Care Plan 28-1) TOP: Nursing Process: Implementation

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: a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder.

D Excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

Client Needs: Psychosocial Integrity 8. A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient 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)

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) REF: Page 325-326 TOP: Nursing Process: Assessment

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

D Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260 TOP: Nursing Process: Assessment

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient's resistance. Guilt and despair might be seen when the nurse experiences the patient's feelings because of empathy. Interest is possible, but not the most likely result. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 260-261 TOP: Nursing Process: Evaluation

A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

D Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14-6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

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

D Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. Autistic spectrum disorder is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

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?" Select 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."

D The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

A psychiatric clinical nurse specialist works with a defendant as a competency evaluator. A staff member asks, "Why are you spending so much time with that defendant? You spend one-to-one time and write volumes. Usually, we give defendants some medication and return them to court." Select the clinical nurse specialist's most appropriate response. A. "My role is to be an advocate for the defendant, so I have to know him well and build a trusting relationship." B. "My focus is providing intensive psychotherapy to ensure the defendant becomes competent before returning to court." C. "The specialized assessments I make on behalf of the court require very lengthy and detailed interviews, so it takes a lot of time." D. "I spend the time observing, assessing, and documenting competency, writing a report, and preparing expert testimony for the court."

D The competency evaluator has to determine the patient's current competence to act on his own behalf during his trial; without competency, the inmate cannot stand trial. Determining competency goes well beyond the mental status, functional, and risk assessments most psychiatric nurses are accustomed to and are very complex and time-consuming. A complete formal report is prepared for the court and all pertinent details addressed in anticipation of questioning by officers of the court. The evaluator represents the court, not the patient. Interviews of the inmate are only a portion of the evaluator's work. Evaluators help the court determine competency but do not intervene to increase the patient's competency.

A child diagnosed with attention deficit hyperactivity disorder 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? The child: 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.

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.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 537-538 | Page 545 (Box 28-7) TOP: Nursing Process: Assessment

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.

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) REF: Page 325-326 | Page 337-338 TOP: Nursing Process: Assessment

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.

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.

Client Needs: Psychosocial Integrity 9. A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient: 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.

D The patient 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 patient is rarely able to see a relation between symptoms and events in his or her life, which is readily discernible to health professionals. Patients 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) REF: Page 325-326 | Page 338 (Nursing Care Plan 17-1) TOP: Nursing Process: Assessment

Which credential would be expected of an expert witness in the area of forensic psychiatric nursing? a. 3 years of experience in an inpatient psychiatric facility b. 10 years of experience in community health nursing c. Educational preparation of an associate degree in nursing d. Publication of three articles in peer-reviewed psychiatric nursing journals

D To establish credibility as an expert witness and have one's opinion given equal weight to that of other professionals in court, the forensic nurse specialist must have current clinical expertise, trustworthiness, and a professional presentation style. The expert witness is an authority in a specialty area. If the expert has conducted research and published in the area, it is an added strength. Expert testimony is based on evidence-based practice. Forensic nurses with advanced degrees are more likely to be called upon as expert witnesses.

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

D When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study/Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

A forensic nurse is appointed as a hostage negotiator by the court. Which appropriate action does the nurse perform? a. the nurse assesses the risk of the victims developing psychiatric conditions b. the nurse assesses the mental status of the victims after their release c.the nurse assists the police officers regularly for 12 hrs/day d. the nurse assess the mental status of the perpetrator after he or she is released

D A forensic nurse should act as a hostage negotiator to assess the mental state of the perpetrator before, during, and after the hostage situation. This helps to identify whether the perpetrator has developed a positive attitude or has negativity toward the society and victims. The hostage nurse does not assess the mental status of the victims. The nurse should assess the mental status of the perpetrator around the clock. This helps to provide effective evidence of the crime to the court. The hostage nurse should help the police officers in the investigation regularly. The nurse should always be available to assist them even at the crime scene

People who have an indigenous worldview A. see themselves as spiritual and believe that they are linked with all other living things. B. focus on the articulation of individual needs and ideas. C. view the self as an extension of cosmic energy that is repeatedly reborn. D. are concerned with being part of a harmonious community.

D. Clients with an indigenous worldview are interested in connectedness and being in harmony with others. They have little interest in personal goals and autonomy.

Deviation from cultural expectations is considered by members of the cultural group as a demonstration of A. hostility. B. lack of self-will. C. variation from tradition. D. illness.

D. Deviation from cultural expectations is considered by others in the culture to be a problem and is frequently defined by the cultural group as "illness."

When assessing and planning treatment for a client who has recently arrived in the United States from China, the nurse should be alert to the possibility that the client's explanatory model for his illness reflects A. supernatural causes. B. negative forces. C. inheritance. D. imbalance.

D. Many Eastern cultures explain illness as a function of imbalance.

Which healing practice is least used in the Western health system of healing practices? A. Antibiotic medication B. Surgery C. Targeted cellular destruction D. Restoring lost balance or harmony

D. The best treatment perspectives of various cultures include regaining lost balance and harmony. This perspective is not used in Western culture.

You are working on the psychiatric unit and assisting with the care for Mr. Tran, a refugee from Darfur, who came to the United States 1 year ago. Although Mr. Tran understands and speaks some very limited English, he is much more comfortable conversing in his native language. Mike, the nurse working directly with Mr. Tran, says to you, "I am so frustrated trying to communicate with Mr. Tran! He insists on speaking his language instead of English. I think if people want to live here, they ought to have to speak our language and act like we do!" Which of the following responses you could make promotes culturally competent care? (select all that apply): A. "You are right that Mr. Tran needs to speak English, but all patients do have a right to an interpreter, so you need to comply." B. "I agree that it is frustrating trying to communicate with Mr. Tran. Maybe we could see if his family members can help convince him to try speaking English." C. "Mr. Tran will have to learn to speak English eventually to live and work successfully in this country. Just try to be patient and encourage him to try speaking English." D. "What you are saying is actually considered cultural imposition, which is imposing our own culture onto someone from a different culture." E. "Mr. Tran's ability to speak and understand English is very limited. He needs to have an interpreter to make sure he can make his needs and feelings known."

D. E. Cultural imposition is imposing our own cultural norms onto those from another cultural group. By obtaining an interpreter for Mr. Tran, the nurse is promoting culturally competent care, ensuring the patient can communicate his feelings and needs thoroughly to the staff. Patients do have a right to an interpreter, but stating that Mike is right is not promoting culturally competent care and is instead confirming his opinion. Asking family members to convince the patient to speak English is not promoting culturally competent care and also undermines the trust between nurse and patient. Instead of encouraging the patient to speak English an interpreter should be obtained for the patient.

On admission, a client experienced severe alcohol withdrawal symptoms. Four days later, the nurse notes a decrease in withdrawal symptoms. Which nursing intervention is most appropriate? A. withhold potentially addictive as needed PRN medications B. Increase PRN medications because potentially fatal complications can still occur. C. Ask the doctor to prescribe a less addictive medication to reduce potential for dependence. D. Monitor for withdrawal complications and administer medications on the basis of client symptoms.

D. Monitor for withdrawal complications and administer medications on the basis of client symptoms The nurse must remain vigilant because withdrawal complications can occur days after initial withdrawal symptoms appear. Medication dosages for withdrawal should be based on an objective assessment of symptoms. This is usually done by the use of an assessment tool such as Clinical Institute Withdrawal Assessment (CIWA)

An individual is found not guilty by reason of insanity after planting explosive devices in a local church. What would be the nurse's expectation regarding this person? The individual: A. was unable to provide useful assistance to the defense attorney. B. will have a new trial after psychiatric stability has been attained. C. will be treated for mental illness in a prison or other forensic setting. D. was unable to act with intent at the time of the offense because of mental illness.

D. The McNaughton rules state that to be considered legally insane, an accused person with a mental disorder either must not know the nature and quality of the act or must not know whether the act is right or wrong. Whereas legal insanity is determined by the defendant's thinking in the past at the time of the offense, competence to proceed is determined by the defendant's present thinking at the time of the trial. It is defined as the capacity to assist one's attorney and understand the legal proceedings. Because competence to proceed is a determination of mental capacity in the present, the defendant's competency must be determined each time he or she goes to court. A prior finding of incompetence, even if caused by a developmental disability or mental illness, does not preclude a subsequent finding of competency in a later, unrelated case. A person found guilty but mentally ill will receive treatment for mental illness in a prison or forensic setting.

A forensic nurse is appointed as an expert witness by the court for a sexual assault case. What is the responsibility of the forensic nurse as an expert witness? A. The nurse should make the defendant feel comfortable. B. The nurse should prove that the defendant is innocent. C. The nurse should testify about the initial care provided to the victim. D. The nurse should provide concise information to the court.

D. The nurse should communicate in a concise and convincing fashion in the court. The nurse should give an expert opinion about the victim's condition and should give a clear medical condition of the victim. This helps the court to make an appropriate judgment. The nurse should not support the defendant and should not try to make the defendant feel comfortable. The nurse should be objective and neutral. The nurse should not act as an advocate to prove the innocence of the defendant. This is considered a breach of professional boundaries. The forensic nurse does not testify regarding the first or initially performed assessments of the victim.

A nurse is undergoing training as a sexual assault nurse examiner in a nursing institute. Which appropriate teaching given to the nurse in the institute indicates effective teaching? A. The nurse is taught for 3 days or 20 contact hours. B. After the course the nurse can directly take care of the victims. C. The nurse is taught how to assess the perpetrator. D. The nurse is taught how to assess and provide care to the victims.

D. The sexual assault nurse examiner is given special training so that he or she can take care of the victims of sexual assault. The training is given for 5 days or 40 contact hours, not for 3 days or 20 contact hours. The nurse cannot directly take care of patients after training. The nurse has to assist a sexual assault nurse examiner expert before being able to take care of the patients individually. The nurse is not taught how to assess perpetrators of sexual assault, as this is the duty of the advanced forensic practice nurse.

Which symptom would the nurse expect to observe in a client experiencing opioid intoxication? A. insomnia B. abdominal cramps C. muscle aches D. impaired judgment

D. impaired judgment impaired judgment; initial euphoria followed by apathy; dysphoria; and psychomotor agitation or retardation are all symptoms of opioid intoxication.

Behaviorists argue that the temporary reduction of tension or raising of spirits produced by a drug has a rewarding effect. This gives evidence that _____ may play a role in substance abuse. A. extinction B. negative reinforcement C. classical conditioning D. operant conditioning

D. operant conditioning

What is the greatest risk coming from cocaine use? A. being assaulted in drug-related crimes B. contracting AIDS C. damage to mucus membranes D. overdose effects

D. overdose effects

Which is the most serious symptom experienced during alcohol withdrawal? A. blackout B. acute withdrawal delirium C. hypotension D. seizure

D. seizure During alcohol withdrawal, the CNS rebounds from the effects of suppression caused by alcohol intake. This excitation of the CNS can lead to grand mal seizures and other complications, which are life threatening. This is the most serious complication of alcohol withdrawal syndrome.

Probably the worst thing one who has "partied hard" with alcohol could do right after drinking would be to: A. drink 4 or more cups of coffee B. eat a small to medium-sized meal C. sleep it off without taking drugs to minimize after effects D. take some barbiturates to fall asleep

D. take some barbiturates to fall asleep

A nurse is caring for a client who has a new prescription for lithium carbonate (Lithobid). When reinforcing teaching about ways to prevent lithium toxicity, the nurse should advise the client to do which of the following? A. Avoid the use of acetaminophen for headaches B. Restrict intake of foods rich in sodium C. Decrease fluid intake to less than 1,500 mL daily D. Limit aerobic activity in hot weather

D.Limit aerobic activity in hot weather

2. A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I may begin to associate my therapists with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "This therapy will address my conscious feelings about stressful experiences." ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

D: Free association is the spontaneous, uncensored verbalization of whatever comes to the client's mind. ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

Communication Disorder

Deficit in language skills acquisition that creates impairments in academic achievement, socialization, or self-care -Speech disorder= sounds; stutter -Language disorder= understanding or using word -Social communication disorder= problems using verbal or nonverbal means for interacting socially; Have to rule out autism Caused by hearing loss, neurological disorders, intellectual disabilities, drug abuse, brain injury, physical problems, and vocal abuse or misuse First step is usually a hearing test

Motor Disorder

Impairments in skill development, or coordination below what would be expected for the child's developmental age and severe enough to interfere with academic achievement or activities of daily living -Stereotypic movement disorder= repetitive, purposeless movements for a period of 4 weeks or greater; more common in boys;safety and prevention of head injury; habit reversal; Naltrexone -Tourette's Syndrome= motor and verbal tics appearing between the ages of 2 and 7; usually the head, change over time; tongue protrusion, touching, squatting, hopping, skipping, retracing steps, and twirling when walking; Vocal tics include spontaneous production of words and sounds; coprolalia is not very common; usually permanent; 90% genetic; coexists with depression, OCD, and ADHD; CNS stimulants make it worse so meds have to be monitored if they also have ADHD; Haloperidol, Pimozide, Ability, Clonidine, Clonazepam, Botox; Habit reversal and Comprehensive Behavior Intervention for Tics (Most promising)-- makes them aware of the tic about to happen; deep brain stimulation

Patients with borderline personality disorder (BPD) exhibit negative effect, which includes emotional _____________, described as rapidly moving from one emotional extreme to another.

Lability

Specific Learning Disorders

Persistent difficulty in the acquisition of : -reading (dyslexia) -mathematics (dyscalculia) -written expression (dysgraphia) More common in males Low self esteem, poor social skills, higher rates of school dropout, difficulties with attaining and maintaining employment, and poorer social adjustment

Q 13. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? 1. Interpreting the compliment as a secret code used to increase personal power 2. Feeling the compliment was well deserved 3. Being grateful for the compliment but fearing later rejection and humiliation 4. Wondering what deep meaning and purpose is attached to the compliment

Q 13 ANS: 3 Rationale: The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the compliment but would fear later rejection and humiliation. Individuals diagnosed with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

Q 21. A highly emotional client presents at an outpatient clinic appointment and states, "My dead husband returned to me during a séance." Which personality disorder should a nurse associate with this behavior? 1. Obsessive-compulsive personality disorder 2. Schizotypal personality disorder 3. Narcissistic personality disorder 4. Borderline personality disorder

Q 21 ANS: 2 Rationale: The nurse should associate schizotypal personality disorder with this behavior. The behaviors of people diagnosed with schizotypal personality disorder are odd and eccentric but do not decompensate to the level of schizophrenia.

Q 28. A client is being assessed for antisocial personality disorder. According to the DSM-5, which of the following symptoms must the client meet in order to be assigned this diagnosis? (Select all that apply.) 1. Ego-centrism and goal setting based on personal gratification. 2. Incapacity for mutually intimate relationships. 3. Frequent feelings of being down miserable and/or hopeless. 4. Disregard for and failure to honor financial and other obligations. 5, Intense feelings of nervousness, tenseness, or panic.

Q 28 ANS: 1, 2, 4 Rationale: The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. Pathological personality traits of antagonism and disinhibition must occur in order to meet the criteria for the diagnosis of antisocial personality disorder. Frequent feelings of being down, miserable, and/or hopeless and intense feelings of nervousness, tenseness, or panic are characteristics of the pathological personality trait domain of negative affectivity. This domain is listed by the DSM-5 for the diagnosis of borderline personality disorder, not antisocial personality disorder.

Q 29. _______________________ personality disorder is characterized by a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way.

Q 29 ANS: Schizoid Rationale: Persons diagnosed with schizoid personality disorder have a profound defect in the ability to form personal relationships or to respond to others in any meaningful emotional way. These individuals display a life-long pattern of social withdrawal, and their discomfort with human interaction is apparent.

Q 30. _____________________ personality disorder is characterized by colorful, dramatic, and extraverted behavior in excitable, emotional people.

Q 30 ANS: Histrionic Rationale: Histrionic personality disorder is characterized by colorful, dramatic, and extraverted behavior in excitable, emotional people. They have difficulty maintaining long-lasting relationships, although they require constant affirmation of approval and acceptance from others.

Q 31. ________________________________ personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation.

Q 31 ANS: Dependent Rationale: Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. These characteristics are evident in the tendency to allow others to make decisions, to feel helpless when alone, to act submissively, to subordinate needs to others, to tolerate mistreatment by others, to demean oneself to gain acceptance, and to fail to function adequately in situations that require assertive or dominant behavior.

32. _____________________ personality disorder is a pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent.

Q 32ANS: Paranoid Rationale: Paranoid personality disorder is a pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This disorder begins in early adulthood and presents in a variety of contexts.

Q 1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the appropriate nursing response to this behavior? 1. "You are very disrespectful. You need to learn to control yourself." 2. "I understand that you are angry, but this behavior will not be tolerated." 3. "What behaviors could you modify to improve this situation?" 4. "What anti-personality disorder medications have helped you in the past?"

Q1 ANS: 2 Rationale: The appropriate nursing response is to reflect the client's feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism.

Q 10. Looking at a slightly bleeding paper cut, the client screams, "Somebody help me quick! I'm bleeding. Call 911!" A nurse should identify this behavior as characteristic of which personality disorder? 1. Schizoid personality disorder 2. Obsessive-compulsive personality disorder 3. Histrionic personality disorder 4. Paranoid personality disorder

Q10 ANS: 3 Rationale: The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals with this disorder tend to be self-dramatizing, attention seeking, over gregarious, and seductive.

Q11. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? 1. The use of highly lethal methods to commit suicide 2. The use of suicidal gestures to elicit a rescue response from others 3. The use of isolation and starvation as suicidal methods 4. The use of self-mutilation to decrease endorphins in the body

Q11 ANS: 2 Rationale: The nurse should expect that a client diagnosed with borderline personality disorder may use suicidal gestures to elicit a rescue response from others. Repetitive, self-mutilating behaviors are common in borderline personality disorders that result from feelings of abandonment following separation from significant others.

Q 14. Which factors differentiate a client diagnosed with social phobia from a client diagnosed with schizoid personality disorder? 1. Clients diagnosed with social phobia are treated with cognitive behavioral therapy, whereas clients diagnosed with schizoid personality disorder need medications. 2. Clients diagnosed with schizoid personality disorder experience anxiety only in social settings, whereas clients diagnosed with social phobia experience generalized anxiety. 3. Clients diagnosed with social phobia avoid attending birthday parties, whereas clients diagnosed with schizoid personality disorder would isolate self on a continual basis. 4. Clients diagnosed with schizoid personality disorder avoid attending birthday parties, whereas clients diagnosed with social phobia would isolate self on a continual basis.

Q14 ANS: 3 Rationale: A client diagnosed with schizoid personality disorder exhibits a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder prefer being alone to being with others and avoid social situations, social contacts, and activities.

Q 17. When planning care for clients diagnosed with personality disorders, what should be the goal of treatment? 1. To stabilize the client's pathology by using the correct combination of psychotropic medications 2. To change the characteristics of the dysfunctional personality 3. To reduce personality trait inflexibility that interferes with functioning and relationships 4. To decrease the prevalence of neurotransmitters at receptor sites

Q17 ANS: 3 Rationale: The goal of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat. There are no psychotropic medications approved specifically for the treatment of personality disorders.

Q18. Which client situation would reflect the impulsive behavior that is commonly associated with borderline personality disorder? 1. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm and whispers, "The night nurse is evil. You have to stay." 2. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm and states, "I will be up all night if you don't stay with me." 3. As the day-shift nurse leaves the unit, the client suddenly hugs the nurse's arm, yelling, "Please don't go! I can't sleep without you being here." 4. As the day-shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, "I cut myself because you are leaving me."

Q18 Ans: 4 Rationale: The client who states, "I cut myself because you are leaving me" reflects impulsive behavior that is commonly associated with borderline personality disorder. Repetitive, self-mutilating behaviors are common in clients diagnosed with borderline personality disorders that result from feelings of abandonment following separation from significant others.

Q19. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with paranoid personality disorder? 1. Risk for violence: directed toward others R/T paranoid thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others

Q19 Ans: 1 Rationale: The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T paranoid thinking. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that result in a constant threat readiness. They are often tense and irritable, which increases the likelihood of violent behavior.

Q2. At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate? 1. "Go ahead and use the phone. I know this pending divorce is stressful." 2. "You know better than to break the rules. I'm surprised at you." 3. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow." 4. "A divorce shouldn't be considered until you have had a good night's sleep."

Q2 ANS: 3 Rationale: The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration.

Q20. From a behavioral perspective, which nursing intervention is appropriate when caring for a client diagnosed with borderline personality disorder? 1. Seclude the client when inappropriate behaviors are exhibited. 2. Contract with the client to reinforce positive behaviors with unit privileges. 3. Teach the purpose of anti-anxiety medications to improve medication compliance. 4. Encourage the client to journal feelings to improve awareness of abandonment issues.

Q20 Ans: 2 Rationale: The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

Q 22. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? 1. "Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling." 2. "Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs." 3. "They tend to develop few relationships because they are strongly independent but generally maintain deep affection." 4. "They pay particular attention to details, which can interfere with the development of relationships."

Q22 ANS: 2 Rationale: The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having relationships that are shallow and fleeting. These types of relationships tend to serve their dependency needs.

Q23. During an interview, which client statement should indicate to a nurse a potential diagnosis of schizotypal personality disorder? 1. "I don't have a problem. My family is inflexible, and relatives are out to get me." 2. "I am so excited about working with you. Have you noticed my new nail polish, 'Ruby Red Roses'?" 3. "I spend all my time tending my bees. I know a whole lot of information about bees." 4. "I am getting a message from the beyond that we have been involved with each other in a previous life."

Q23 ANS: 4 Rationale: The nurse should assess that a client who states that he or she is getting a message from beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The person experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

Q24. Which nursing diagnosis should be prioritized when providing nursing care to a client diagnosed with avoidant personality disorder? 1. Risk for violence: directed toward others R/T paranoid thinking 2. Risk for suicide R/T altered thought 3. Altered sensory perception R/T increased levels of anxiety 4. Social isolation R/T inability to relate to others

Q24 ANS: 4 Rationale: The priority nursing diagnosis for a client diagnosed with avoidant personality disorder should be social isolation R/T inability to relate to others. These clients avoid close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

Q26. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? (Select all that apply.) 1. The client will relate one empathetic statement to another client in group by day two. 2. The client will identify one personal limitation by day one. 3. The client will acknowledge one strength that another client possesses by day two. 4. The client will list four personal strengths by day three. 5. The client will list two lifetime achievements by discharge.

Q26 ANS: 1, 2, 3 Rationale: The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. Narcissistic personality disorder is characterized by an exaggerated sense of self-worth, a lack of empathy, and exploitation of others.

Q27. A nurse is caring for a client diagnosed with antisocial personality disorder. Which factors should the nurse consider when planning this client's care? (Select all that apply.) 1. This client has personality traits that are deeply ingrained and difficult to modify. 2. This client needs medication to treat the underlying physiological pathology. 3. This client uses manipulation, making the implementation of treatment problematic. 4. This client has poor impulse control that hinders compliance with a plan of care. 5. This client is likely to have secondary diagnoses of substance abuse and depression.

Q27 ANS: 1, 3, 4, 5 Rationale: The nurse should consider that individuals diagnosed with antisocial personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse or depression.

Q3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? 1. Provide objective evidence that reasons for violence are unwarranted. 2. Initially restrain the client to maintain safety. 3. Use clear, calm statements and a confident physical stance. 4. Empathize with the client's paranoid perceptions.

Q3 ANS: 3 Rationale: The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

Q 4. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? 1. Allow the clients to apply the democratic process when developing unit rules. 2. Maintain consistency of care by open communication to avoid staff manipulation. 3. Allow the client spokesman to verbalize concerns during a unit staff meeting. 4. Maintain unit order by the application of autocratic leadership.

Q4 ANS: 2 Rationale: The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

Q 6. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? 1. A physically healthy client who is dependent on meeting social needs by contact with 15 cat 2. A physically healthy client who has a history of depending on intense relationships to meet basic needs 3. A physically healthy client who lives with parents and depends on public transportation 4. A physically healthy client who is serious, inflexible, perfectionistic, lacks spontaneity, and depends on rules to provide security

Q6 ANS: 3 Rationale: A physically healthy adult client who lives with parents and depends on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviors.

Q7. A client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of "suffering" in silence. Which statement best explains the etiology of this client's personality disorder? 1. Childhood nurturance was provided from many sources, and independent behaviors were encouraged. 2. Childhood nurturance was provided exclusively from one source, and independent behaviors were discouraged. 3. Childhood nurturance was provided exclusively from one source, and independent behaviors were encouraged. 4. Childhood nurturance was provided from many sources, and independent behaviors were discouraged.

Q7 Ans: 2 Rationale: The behaviors presented in the question represent symptoms of dependent personality disorder. Nurturance provided from one source and discouragement of independent behaviors can contribute to the development of this personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

Q8. Family members of a client ask the nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing response? 1. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. 2. Clients diagnosed with schizoid personality disorder exhibit delusions and hallucinations, while clients diagnosed with avoidant personality disorder do not. 3. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. 4. Clients diagnosed with schizoid personality disorder have a history of psychosis, while clients diagnosed with avoidant personality disorder remain based in reality.

Q8 Ans: 1 Rationale: The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, while clients diagnosed with schizoid personality disorder prefer to be alone. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships. Clients diagnosed with schizoid personality disorder may exhibit odd and eccentric behaviors but not to the extent of psychosis.

Tx for all impulse disorders [intermittent explosive disorder, pyromania, kleptomania]?

SSRI's + Group Therapy (but none of these are really that great)

What is a powerful predictor of substance use and abuse in later life?

Temperament and behavioral traits including: shyness, aggressiveness, and rebelliousness

Resilience

The relationship between a child's inborn strengths and that child's success in handling stressful environmental factors

define Temperament

The style of behavior a child habitually uses to cope with the demands and expectations of the environment

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? a. "life isn't worth living if I gain weight." b. "don't pretend like you don't know how fat I am." c. "if i could be skinny, I know I'd be popular." d. "when I look in the mirror, I see myself as obese."

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

A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment? SELECT ALL THAT APPLY a. "what is your relationship like with your family?" b. "why do you want to lose weight?" c. "would you describe your current eating habits?" d. "at what weight do you believe you will look better?" e. "can you discuss you feelings about your appearance?"

a. "what is your relationship like with your family?" c. "would you describe your current eating habits?" e. "can you discuss you feelings about your appearance?"

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.

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. The patient 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 ones 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 patient (blackouts). See relationship to audience response question.

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 posttraumatic stress disorder (PTSD) is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

a. Reexperiencing 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.

Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

a. engage the parasympathetic nervous system. 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.

After the sudden death of his wife, a man says, "I can't live without her...she was my whole life." Select 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."

b. "Her death is a terrible loss for you." Adjustment disorders may be associated with grief. A statement that validates a bereaved persons loss is more helpful than false reassurances and clichs. It signifies understanding.

Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic 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."

b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." The correct response indicates the soldier is thinking about death and feeling survivors guilt. These emotions may accompany suicidal ideation, which warrants the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. 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.

The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select 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."

b. "Use short, simple sentences and keep the environment calm and protective." Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients 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 patient should only gradually be given information about her past. Asking questions that require recall that the patient does not possess will only add frustration. Quiet, undemanding activities should be provided as the patient tolerates them and should be balanced with rest periods; the patients time should not be loaded with demanding or stimulating activities.

A nurse works with a patient diagnosed with posttraumatic stress disorder 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 patient 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.

b. Explain that the physical symptoms are related to the psychological state. Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the bodys responses to psychological trauma helps the patient 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 patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.

The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks Cortisol is a hormone released in response to stress. Severe dissociation or mindflight occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? SELECT ALL THAT APPLY a. amenorrhea b. hypokalemia c. mottling of the skin d. slightly elevated body weight e. presence of lanugo on the face

b. hypokalemia d. slightly elevated body weight

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following response should the nurse make? a. "many clients are concerned about their weight. However, the dietician will ensure that you don;t get too many calories in your diet." b. "Instead of worrying about your weight, try to focus on other problems at this time." c. "I understand you have concerns about you weight, but first, let's talk about your recent accomplishments." d. "you are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

c. "I understand you have concerns about you weight, but first, let's talk about your recent accomplishments." this statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments which can promote client self-esteem and self-image

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 patient had ambivalent feelings about her husband.

c. Anger is an expected emotion in an adjustment disorder. 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.

A soldier who served in a combat zone returned to the U.S. 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 posttraumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

c. Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals 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.

A patient 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

c. Depersonalization disorder 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 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 patient experiences only one symptom.

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

c. Sympathetic nervous system 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.

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

c. depression. 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.

After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

c. hippocampus. The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.

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. Select 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."

d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings. Crying at 2 weeks after his death is expected and normal.

Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: 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.

d. cognitive distortions associated with unresolved childhood abuse issues. Nearly all patients with dissociative identity disorder have a history of childhood abuse or trauma. None of the other etiology statements is relevant. See relationship to audience response question.

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school.

d. create a scholarship fund at their child's high school. 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.

A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions should the nurse include in the client's plan of care? a. allow the client to select preferred meal times b. establish consequences for purging behavior c. provide the client with a high-fat diet at the start of treatment d. implement one-to-one observation during meal times

d. implement one-to-one observation during meal times

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

d. throw flowers on the lake at each anniversary date of the accident. 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.