Practice questions for Exam 4

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

a A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

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

a Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with ADHD. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.

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

a CNS stimulants, such as methylphenidate and pemoline, increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with ADHD. The other medication categories listed would not be appropriate.

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

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.

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

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.

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

a Clients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the client is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the client. Clients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

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

a Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

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

a Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression.

Which nursing intervention has the highest priority for a client diagnosed with bulimia nervosa? a. Assist the client 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.

a For most clients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.

A nurse provides care for an adolescent client diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the client in a protective fashion. b. The nurse's comments to the client are compassionate and nonjudgmental. c. The nurse teaches the client to recognize signs of increasing anxiety and ways to intervene d. The nurse refers the client to a self-help group for individuals with eating disorders.

a In the effort to motivate the client and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parent's role. The helpful nurse uses a problem-solving approach and focuses on the client's feelings of shame and low self-esteem. Referring a client to a self-help group is an appropriate intervention.

The treatment team discusses adding a new prescription for lisdexamfetamine dimesylate to the plan of care for a client diagnosed with binge eating disorder. Which finding from the nursing assessment is most important for the nurse to share with the team? a. The client's history of poly-substance abuse b. The client's preference for homeopathic remedies c. The client's family history of autoimmune disorders d. The client's comorbid diagnosis of a learning disability

a Lisdexamfetamine dimesylate is designed to suppress the appetite and presents a risk for abuse. The client with a history of substance abuse is at risk to abuse this medication as well. The client's preference for homeopathic remedies is a consideration, but the history of substance abuse has a higher priority. Lisdexamfetamine dimesylate is commonly used to treat attention deficit hyperactivity disorder rather than learning disabilities. A history of autoimmune disorders in the family is irrelevant.

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

a Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Clients with antisocial personality disorders rarely have feelings of fear and inferiority.

One bed is available on the inpatient eating-disorder unit. A client with which assessment data should be admitted to this bed? a. Going from 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. Going from120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. Going from110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. Going 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg

a Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, weighs below 75% of ideal body weight, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

A 7-year-old child was diagnosed with pica. Which assessment finding would the nurse expect associated with this diagnosis? a. The child frequently eats newspapers and magazines. b. The child refuses to eat peanut butter and jelly sandwiches. c. The child often rechews and re-swallows foods at mealtimes. d. The parents feed the child clay because of concerns about anemia.

a Pica refers to eating nonfood items after maturing past toddlerhood. Some cultures practice eating nonfood items; however, this factor is a cultural preference rather than a disorder. Refusing to eat peanut butter and jelly sandwiches is an example of a simple food preference in a child. Rumination refers to regurgitation with rechewing, re-swallowing, or spitting.

What does the physical assessment of a client diagnosed with bulimia often reveal? a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

a Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.

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

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.

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

a Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

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

a The client is showing openness to learning techniques for impulse control. One technique is to teach the client to stop and think before acting impulsively. The client can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

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

a The client with moderately severe dementia has memory loss that begins to interfere with activities. This client may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the client in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the client to a urinary tract infection.

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

a The desired overall goal is that the delirious client will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a client whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a client with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a client with sensorium problems related to delirium.

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

a The scenario describes self-mutilation. Self-mutilation is a nursing diagnosis relating to client safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the client with borderline personality disorder.

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.

A client 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 client 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."

a Untreated clients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The client with anorexia will usually tell people perceptions of self. The client with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.

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

a Violence against property, along with threats to harm staff, makes this diagnosis the priority. Clients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When clients with antisocial personality disorders use denial, they use it effectively.

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the client gained 8 pounds. What intervention should the nurse implement initially? a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the client for the weight gain. d. establish a higher goal for weight gain the next week.

a Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

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

a, b, c Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Clients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression.

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

a, b, e Providing clothing with elastic and hook-and-loop closures facilitates client independence. Labeling clothing with the client's name and the name of the item maintains client identity and dignity (provides information if the client has agnosia). When a client resists, it is appropriate to use distraction and try again after a short interval because client's moods are often labile. The client may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the client to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

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

a, c Familial risk factors that correlate with child psychiatric disorders include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. Having a parent with a substance abuse problem increases the risk of marital discord. A family history of schizophrenia presents a genetic risk. Being in a middle-income family, living in an urban community, and being an only or oldest child do not represent adversity.

A client referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa should a nurse assess? (Select all that apply.) a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

a, c, d, f Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

A client diagnosed with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the client 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. Client involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the client's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

b A sense of control for the client is vital to the success of therapy. A diet that controls weight gain can allay client fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

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

b Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the client will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the client's safety.

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

b Maintaining consistent limits is by far the most difficult intervention because of the client's superior skills at manipulation. Supporting behavioral change and monitoring client safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques.

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

b Memory impairment begins at the mild stage and progresses in the subsequent stages. This client is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

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

b Mood stabilizing medications have been effective for many clients with borderline personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for clients who are impulsive.

What is an appropriate intervention for a client diagnosed with bulimia nervosa who binges, and purges is to teach the client? 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.

b One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the client to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the client to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.

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

b Placing door locks at the top of the door makes it more difficult for the client with dementia to unlock the door because the ability to look up and reach upward is diminished. The client will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the client's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the client leaves the home, but it does not prevent wandering or assure the client's safety.

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

b Reorientation may seem like arguing to a client with cognitive deficit and increases the client's anxiety. Validating, talking with the client about familiar, meaningful things, and reminiscing give meaning to existence both for the client and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because clients with dementia sometimes become more agitated with reorientation.

Which personality characteristic is a nurse most likely to assess in a client diagnosed with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

b Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of clients with eating disorders. The incorrect options are rare in a client with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.

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. Encouraging the victimized child to share feelings about the experience provides the nurse an opportunity to further assess the situation as well as provide support to the child. The nurse should validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

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

b The listed cerebral pathophysiologies are all associated with development of dementia.

Which nursing intervention has the highest priority as a client 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 client's feelings. d. Help the client balance energy expenditures with caloric intake.

b The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relates to coping. Helping the client achieve balance between energy expenditure and caloric intake is an inappropriate intervention.

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

b The pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

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

b Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

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

b, c, d The nurse's focus is safety, including online environments. Education and awareness-based approaches are indicated to reduce the risks of potentially harmful behavior, including risks associated with cyberbullying. Parental controls on the children's devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family's network password and an invasion of privacy to inspect sites family members have visited.

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 is important for the nurse to use current terminology.

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

c A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the client is able to behave appropriately.

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

c Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

A client referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the client which question? 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?"

c Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the client often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the client's thoughts on present weight explores the client's feelings about weight.

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

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

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

c Because of their disruptive behaviors, children diagnosed with attention deficit hyperactivity disorder (ADHD) often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

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

c Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD.

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

c Clients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The client is displaying the opposite of detached behavior. Guilt is not evident in the comments.

Why does the nurse conducting group therapy on the eating-disorder unit schedule the sessions immediately after meals? a. maintains clients' concentration and attention. b. shifts the clients' focus from food to psychotherapy. c. promotes processing of anxiety associated with eating. d. focuses on weight control mechanisms and food preparation.

c Eating produces high anxiety for clients with eating disorders. Anxiety levels must be lowered if the client is to be successful in attaining therapeutic goals. Shifting the clients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining clients' concentration and attention is important, but not the primary purpose of the schedule.

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

c Families should be made aware that the client will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease.

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

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.

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

c Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

A nurse provides health teaching for a client diagnosed with bulimia nervosa. What is the priority information the nurse should provide? 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.

c Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the client can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the client purges. Daily weight gain may not be desirable for a client with bulimia nervosa. Self- esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

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

c In the middle stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the late stage there is severe cognitive decline along with agraphia, hyperorality, blunting of emotions, visual agnosia, and hypermetamorphosis. Sundowning is not a stage of Alzheimer's disease.

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

c It uses instruction, role playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

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

c Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

Over the past year, a client has cooked gourmet meals for the family but eats only tiny servings. This person wears layered loose clothing and currently weighs 95 pounds, after 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

c Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The client with eating disorder not otherwise specified may be obese.

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

c Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

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

c Separating and distracting prevents escalation from verbal to physical acting out. Neither client loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening clients is an unsafe action and trying to reinforce reality during an angry outburst will probably not be successful when the clients are cognitively impaired.

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

c The client has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the client to choose an alternative to self- mutilation. The need for a protective environment may not be necessary if the client is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the client's ability to weigh alternatives to mutilating behavior.

As a client admitted to the eating-disorder unit undresses, a nurse observes that the client's body is covered by fine, downy hair. The client weighs 70 pounds and is 5'4" tall. Which term should be used in the documentation of this assessment finding? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

c The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in clients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

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

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.

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

c The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.

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

c The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the client's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic.

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

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.

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.

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

c This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The client would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.

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.

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

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 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.

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.

A client diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? (Select all that apply.) a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

c, d, e Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the client's eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe clients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

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

c, d, e The correct answers are consistent with problems frequently identified for clients with late- stage Alzheimer's disease. Confusion is chronic, not acute. The client's cognition is too impaired to grieve.

A nurse finds a client 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."

d A matter-of-fact statement that the nurse's perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Clients must be held accountable for required behaviors.

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

d Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

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

d Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD.

Disturbed body image is a nursing diagnosis established for a client 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 client d. Client expresses satisfaction with body appearance

d Body image disturbances are considered improved or resolved when the client is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.

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

d Excessive motion, distractibility, and excessive talkativeness are seen in ADHD. The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

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

d In severe (late-stage) dementia, the client often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the client is to live. The client is incapable of self-care, ambulation, or verbal communication.

Outpatient treatment is planned for a client diagnosed with anorexia nervosa. What is the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements that should be achieved within 1 week? a. weighs self accurately using balanced scales. b. limits exercise to less than 2 hours daily. c. selects clothing that fits properly. d. gains 1 to 2 pounds.

d Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the client is an outpatient. The focus of an outcome would not be on the client weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

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

d Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The client's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.

The nursing care plan for a client 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

d Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the client's physiological integrity. The other body systems are not initially involved in the refeeding syndrome.

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. ASD is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

Which assessment finding for a client diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hour b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg

d Systolic blood pressure less than 90 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hour. A potassium level of 3.4 mEq/L is within the normal range.

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

d The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in clients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Clients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

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

d The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

Which nursing diagnosis is more appropriate for a client diagnosed with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound client diagnosed with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

d The client with bulimia nervosa usually maintains a close to normal weight, whereas the client with anorexia nervosa may approach starvation. The incorrect options may be appropriate for clients with either anorexia nervosa or bulimia nervosa.

A client was diagnosed with anorexia nervosa. The history shows the client virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? a. Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

d The client's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the client uses laxatives, induces vomiting, or exercises excessively. The client has hypokalemia rather than hyperkalemia.

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for a client 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."

d The correct response is the only strategy that questions the client's distorted thinking.

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

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.

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.

A nursing diagnosis for a client diagnosed with bulimia nervosa is Ineffective coping related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. What is the best outcome related to this diagnosis that should be achieved within 2 weeks? a. appropriately expressing angry feelings. b. verbalizing two positive things about self. c. verbalizing the importance of eating a balanced diet. d. identifying two alternative methods of coping with loneliness.

d The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

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

d The person with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Persons with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are commonly observed with other psychiatric conditions.

A client being admitted to the eating-disorder unit has a yellow cast to the skin and fine, downy hair over the trunk. The client weighs 70 pounds; height is 5'4". The client says, "I won't eat until I look thin." What is 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

d The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the client's self-starvation is the priority.

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

d Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in clients with dementia.

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

d When hallucinations are present, the nurse should acknowledge the client's feelings and state the nurse's perception of reality, but not argue. Staying with the client increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the client's perception without offering help does not support the client emotionally. Telling the client to relax makes the client responsible for self-soothing. Telling the client that someone will brush the bugs away supports the perceptual distortions.