Nclex Sem 3 Unit 5
Which intervention is focused on facilitating socialization of the cognitively impaired child? a. Provide age-appropriate toys and play activities. b. Provide peer experiences such as Special Olympics when older. c. Avoid exposure to strangers who may not understand cognitive development. d. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
ANS: B
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.
ANS: B
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism
ANS: B
A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tremulous and anxious. Which action by the nurse is appropriate? a. Encourage increased oral intake. b. Insert an IV line and infuse fluids. c. Provide a quiet, well-lit environment. d. Administer opioids to provide sedation.
ANS: C
A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. administering chloral hydrate for sedation. b. feeding every 4 to 6 hours to allow extra rest. c. swaddling the infant snugly and holding the baby tightly. d. playing soft music during feeding.
ANS: C
A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana
ANS: A
An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.
ANS: A
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
An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient: a. to eat a small meal after purging. b. not to skip meals or restrict food. c. to increase oral intake after 4 PM daily. d. the value of reading journal entries aloud to others.
ANS: B
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."
ANS: B
The weight loss of anorexia nervosa is often triggered by what event? a. Sexual abuse b. School failure c. Independence from family d. Traumatic interpersonal conflict
ANS: D
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
When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.
ANS: D
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
A patient diagnosed with anorexia nervosa virtually stopped eating 5 months ago and lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I am fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."
ANS: A
A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"
ANS: C
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.
ANS: D
Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa who purges? a. Powerlessness. b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements
ANS: D
Which statement is most descriptive of bulimia during adolescence? a. Strong sense of control over eating behavior b. Feelings of elation after the binge-purge cycle c. Profound lack of awareness that the eating pattern is abnormal d. Weight that can be normal, slightly above normal, or below normal
ANS: D
11. 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
ANS: A
A careful review of the literature on the various recreational and illicit drugs reveals that: a. more longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. b. heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not. c. mothers should discontinue heroin use (detox) any time they can during pregnancy. d. methadone withdrawal for infants is less severe and shorter than heroin withdrawal.
ANS: A
A child with autism spectrum disorder (ASD) is admitted to the hospital with pneumonia. The nurse should plan which priority intervention when caring for the child? a. Maintain a structured routine and keep stimulation to a minimum. b. Place the child in a room with a roommate of the same age. c. Maintain frequent touch and eye contact with the child. d. Take the child frequently to the playroom to play with other children.
ANS: A
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."
ANS: A
A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.
ANS: A
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
Physical assessment of a patient diagnosed with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair.. d. 25% underweight.
ANS: A
Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Social isolation b. Decisional conflict c. Chronic low self-esteem d. Disturbed personal identity
ANS: A
The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol b. Tobacco c. Marijuana d. Heroin
ANS: A
Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, "I am using contraceptives." c. says, "I feel full after eating a small meal." d. reports problems with dry mouth and constipation.
ANS: A
When should a child diagnosed with cognitive impairment be referred for stimulation and educational programs? a. As young as possible. b. As soon as they have the ability to communicate in some way. c. At age 3 years, when schools are required to provide services. d. At age 5 or 6 years, when schools are required to provide services.
ANS: A
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
ANS: A
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore needs for health teaching.
ANS: A
A 9 year old diagnosed with Down syndrome is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurse's recommendation should be based on what knowledge? a. Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. b. Children with Down syndrome have the same need for socialization as other children. c. Children with Down syndrome socialize better with children who have similar disabilities. d. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.
ANS: B
A child with autism is hospitalized with asthma. The nurse should plan care so that the: a. parents' expectations are met. b. child's routine habits and preferences are maintained. c. child is supported through the autistic crisis. d. parents need not be at the hospital.
ANS: B
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
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: a. microcephaly. b. Down syndrome. c. cerebral palsy. d. fragile X syndrome.
ANS: B
A nurse is providing a parent information regarding autism spectrum disorder (ASD). Which statement made by the parent indicates understanding of the teaching? a. "Autism is characterized by periods of remission and exacerbation." b. "The onset of autism usually occurs before toddler stage." c. "Children with autism have imitation and gesturing skills." d. "Autism can be treated effectively with medication."
ANS: 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.
ANS: B
A parent whose child has been diagnosed with a cognitive deficit should be counseled about what fact related to intellectual impairment? a. Is usually due to a genetic defect. b. Is likely caused by a variety of factors. c. Is rarely due to first-trimester events. d. Is usually caused by parental intellectual impairment.
ANS: B
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
A patient diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. b. Patient involvement in decision making increases sense of control and promotes compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.
ANS: B
A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first? a. Teach the patient about the importance of good nutrition. b. Serve multiple small feedings of high-calorie, high-protein foods. c. Consult with the health care provider about parenteral nutrition (PN). d. Obtain an order for enteral feedings of liquid nutritional supplements.
ANS: B
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.
ANS: B
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.
ANS: B
A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. What withdrawal signs does the nurse expect? a. Tremors and seizures b. Vomiting and diarrhea c. Lethargy and disorientation d. Delusions and hallucinations
ANS: B
A patient who smokes a pack of cigarettes per day tells the nurse, "I enjoy smoking and have no plans to quit." Which nursing diagnosis is most appropriate? a. Health-seeking behaviors related to cigarette use b. Ineffective health maintenance related to tobacco use c. Readiness for enhanced self-health management related to smoking d. Deficient knowledge related to long-term effects of cigarette smoking
ANS: B
A severely malnourished patient reports that he is Jewish. The nurse's initial action to meet his nutritional needs will be to a. have family members bring in food. b. ask the patient about food preferences. c. teach the patient about nutritious Kosher foods. d. order nutrition supplements that are manufactured Kosher.
ANS: B
Which action should the nurse take first when preparing to teach a frail 79-yr-old Hispanic man who lives with an adult daughter about ways to improve nutrition? a. Ask the daughter about the patient's food preferences. b. Determine who shops for groceries and prepares the meals. c. Question the patient about how many meals per day are eaten. d. Assure the patient that culturally preferred foods will be included.
ANS: B
A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center.
ANS: C
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
ANS: C
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."
ANS: C
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
ANS: C
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.
ANS: C
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients' concentration and attention. b. shifting the patients' focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.
ANS: C
A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. how to recognize hypokalemia. d. self-esteem maintenance.
ANS: C
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) b. Imipramine (Tofranil) c. Methyphenidate (Ritalin) d. Carbamazepine (Tegretol)
ANS: C
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
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."
ANS: C
After receiving change-of-shift report on four patients who are undergoing substance use treatment, which patient will the nurse assess first? a. A patient who has just arrived for alcohol use treatment and states that the last drink was 2 hours ago b. A patient who is agitated and experiencing nausea, occasional vomiting, and diarrhea while withdrawing from heroin c. A patient who has tremors secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago d. A patient who is being treated for cocaine addiction and is irritable and disoriented, with a pulse rate of 112 beats/min
ANS: C
Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is: a. phobias. b. panic disorder. c. posttraumatic stress disorder (PTSD). d. obsessive-compulsive disorder (OCD).
ANS: C
In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech, and language problems) are often not detected until the child goes to school. d. both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
ANS: C
Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified
ANS: C
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. pharmacologic treatment. b. reduction of environmental stimuli. c. neonatal abstinence syndrome scoring. d. adequate nutrition and maintenance of fluid and electrolyte balance.
ANS: C
The child diagnosed with Down syndrome should be evaluated for which characteristic before participating in some sports? a. Hyperflexibility b. Cutis marmorata c. Atlantoaxial instability d. Speckling of iris (Brushfield's spots)
ANS: C
The nurse is planning care for a patient who is chronically malnourished. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assist the patient to choose high-nutrition items from the menu. b. Monitor the patient for skin breakdown over the bony prominences. c. Offer the patient the prescribed nutritional supplement between meals. d. Assess the patient's strength while ambulating the patient in the room.
ANS: C
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
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
ANS: C
What should the nurse keep in mind when planning to communicate with a child who is diagnosed with an autism spectrum disorder (ASD)? a. The child has normal verbal communication. b. The child is expected to use sign language. c. The child may exhibit monotone speech and echolalia. d. The child is not listening if he/she is not looking at the nurse.
ANS: C
Which action is contraindicated when a child diagnosed with Down syndrome is hospitalized? a. Determine the child's vocabulary for specific body functions. b. Assess the child's hearing and visual capabilities. c. Encourage parents to leave the child alone at night. d. Have meals served at the child's usual mealtimes.
ANS: C
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.
ANS: C
Which is the most common congenital anomaly associated with Down syndrome? a. Hypospadias b. Pyloric stenosis c. Septal defects d. Congenital hip dysplasia
ANS: C
A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, "Nothing on the menu sounds good." Which action by the nurse will be most effective in improving the patient's oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Have family members bring favorite foods.
ANS: D
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.
ANS: D
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.
ANS: D
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?"
ANS: D
A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."
ANS: D
A nursing diagnosis for a patient diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.
ANS: D
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
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, "I won't eat until I look thin." Select the priority initial nursing diagnosis. a. Anxiety related to fear of weight gain b. Disturbed body image related to weight loss c. Ineffective coping related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements related to self-starvation
ANS: D
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.
ANS: D
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
A patient who is morbidly obese states, "I've recently made some changes in my life. I've decreased my fat intake, and I've stopped smoking." Which statement, if made by the nurse, is the best initial response? a. "Although those are important, it is essential that you make other changes, too." b. "Are you having any difficulty in maintaining the changes you have already made?" c. "Which additional changes in your lifestyle would you like to implement at this time?" d. "You have already accomplished changes that are important for the health of your heart."
ANS: D
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
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.
ANS: D
A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."
ANS: D
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat congruence with height, frame, age, and sex b. Calorie intake is within required parameters of treatment plan c. Weight reaches established normal range for the patient d. Patient expresses satisfaction with body appearance
ANS: D
How may anorexia nervosa best be described? a. Occurring most frequently in adolescent males. b. Occurring most frequently in adolescents from lower socioeconomic groups. c. Resulting from a posterior pituitary disorder. d. Resulting in severe weight loss in the absence of obvious physical causes.
ANS: D
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.
ANS: D
The long-term treatment plan for an adolescent with an eating disorder focuses on: a. managing the effects of malnutrition. b. establishing sufficient caloric intake. c. improving family dynamics. d. restructuring perception of body image.
ANS: D
The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Integumentary d. Cardiovascular
ANS: D
