Psych CH 38, 39, & 40

40 When a terminally ill patient is attempting to make the decision to withhold further treatment, the nurse would indicate that which medication would no longer be prescribed if treatment were to be withheld? a. Antibiotics b. Antiemetics c. Opioid analgesics d. Nonopioid analgesics

A Antibiotics are used to treat infection and therefore would be withheld in the care of a patient who has designated that life-sustaining treatment should be withheld. The medications in the other options promote comfort and would continue to be administered. DIF: Cognitive Level: Application REF: Text Page: 768 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care

40 A patient with liver failure rings the call bell and tells the nurse, "The lunch is cold, and my sheets are wrinkled. You never seem to have enough help to give me the care I need." Which intervention should the nurse implement initially? a. Listen quietly but attentively until the patient has finished speaking. b. Attempt to correct each problem the patient has identified immediately. c. Say to the patient, "I'm sorry but please know that the staff is really doing the best they can." d. Promise the patient to share all of the concerns with the unit's nurse manager on day shift.

A Ways in which the nurse can respond to patient or family concerns include, among others, listening without interrupting or defending, and providing what is requested if possible. For this reason, the nurse should initially listen to the patient before attempting to correct the perceived problems. DIF: Cognitive Level: Application REF: Text Pages: 762-763 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A patient receiving palliative care is treated with large doses of narcotic analgesics to control pain. To minimize side effects of this medication the nurse should ensure that there is a prn prescription for which type of medication? a. Antiemetic b. Stool softener c. Bronchodilator d. Nonopioid analgesic

B Constipation occurs in as many as two thirds of patients receiving palliative care. Patients taking narcotic pain-control agents regularly should have prophylactic treatment for constipation, which could include stool softeners and laxatives. DIF: Cognitive Level: Application REF: Text Page: 766 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

40 A patient with end-stage renal disease does not want further aggressive treatment but is reluctant to withdraw life-sustaining treatment. The nurse would help the patient to understand that life-sustaining treatment includes maintaining: a. full code status. b. comfort measures only. c. nutrition, hydration, and dialysis. d. nutrition and hydration but removal of dialysis.

C The patient who wants to withhold further aggressive therapy but not withdraw life-sustaining therapy would be informed that nutrition, hydration, and current treatments such as dialysis would be maintained. DIF: Cognitive Level: Application REF: Text Pages: 767-768 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment: Management of Care

40 A nurse is working with the family of a terminally ill child with leukemia. The nurse shares with the parents that which sibling will likely have a more factual than emotional response to the sibling's death? a. 16-year-old b. 12-year-old c. 8-year-old d. 3-year-old

D Below the age of 6 years, attitudes toward death are often matter-of-fact rather than emotional. DIF: Cognitive Level: Comprehension REF: Text Page: 769 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

39 Which statement by a military veteran being treated for posttraumatic stress disorder (PTSD) is the strongest evidence that the condition is being managed? a. "My mother said that I am much more like my old self." b. "I hope my buddies get the type of professional help I'm getting." c. "I didn't think my nightmares would ever stop but now I'm not so sure." d. "My children and I went to the fireworks display and we all really enjoyed it."

D A hyperactive startle reflex is a common characteristic of PTSD. Being able enjoy a noisy, explosive display of fireworks would be the best indicator of the disorder presented by the options. The other options demonstrate hope and confidence in treatment but not actual behavioral changes. DIF: Cognitive Level: Analysis REF: Text Page: 753 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity: Physiological Integrity

38 An older adult patient exhibits bilateral bruising for the second time on both upper outer arms. When the nurse questions the patient about the bruising, the patient starts to cry and pleads, "Please don't say anything. It's not my daughter's fault. I just bruise easily." Which intervention reflects the best management of this situation? a. Calling the daughter to discuss both the bruising and her parent's reaction b. Reporting the elder abuse and informing the patient and the daughter of the action c. Notifying the patient's social worker of the bruising after a complete assessment has been completed d. Informing the patient and the daughter of the nurse's obligation to document the bruising and report the findings to protective services

D Although it is often difficult to differentiate elder abuse, bilateral bruising on the upper outer arms is a definitive sign. The nurse is responsible for reporting such findings and continuing vigilant observation for further signs of elder abuse and neglect. It is usually best to inform the family of your intention to report elder abuse with the expressed purpose of obtaining help for both; this makes protective services less threatening and preserves the nurse's therapeutic alliance. DIF: Cognitive Level: Application REF: Text Page: 742 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 Which patient is at greatest risk for physical abuse by a family member? a. A 15-year-old who lives with a single parent in an inner city apartment complex b. An 8-year-old who is mentally challenged and living with a foster family c. A 30-year-old adult who shares a home with a homosexual partner d. A 79-year-old with chronic depression who lives with a grandchild

D Among the aspects putting the 79-year-old patient at greatest risk for physical abuse by a family member are being elderly and experiencing a psychiatric illness. DIF: Cognitive Level: Analysis REF: Text Pages: 745-746 TOP: Nursing Process: Diagnosis|Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity

40 A nurse advocating for an anxious patient newly diagnosed with a life-threatening illness would ask the health care provider to prescribe which type of medication? a. Selective serotonin reuptake inhibitor b. Monoamine oxidase inhibitor c. Tricyclic antidepressant d. Benzodiazepine

D The patient's symptoms of anxiety need not meet the criteria for a formal psychiatric diagnosis in order to be treated. Pharmacological treatment with benzodiazepines is common practice, and nurses should initiate requests for a prescription if the patient does not already have one. DIF: Cognitive Level: Application REF: Text Page: 764 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

40 A patient undergoing chemotherapy is experiencing anxiety-induced anticipatory nausea and vomiting. A nurse could assist this patient by requesting a prescription for which preferred medication? a. Lorazepam (Ativan) b. Hydroxyzine (Vistaril) c. Promethazine (Phenergan) d. Chlorpromazine (Thorazine)

A Because the nausea and vomiting are anxiety-induced, lorazepam (a benzodiazepine) may be used to reduce both the anxiety and the nausea and vomiting. The other medications listed are useful in treatment of nausea and vomiting. DIF: Cognitive Level: Application REF: Text Page: 766 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies

40 A nurse explained hospice services to a patient with metastatic cancer. In evaluating the teaching, the nurse determines the need for further information when the patient states that one of the services provided in hospice care is: a. experimental chemotherapy. b. symptom management. c. psychosocial support. d. nutritional counseling.

A Hospice care would not include any form of chemotherapy, which is a therapy generally intended to treat or cure cancer. Hospice care does involve pain and symptom management, nutritional counseling, physical/occupational/speech therapies, home health services for personal care, psychosocial and emotional support, grief counseling, and crisis care during medical emergencies. DIF: Cognitive Level: Application REF: Text Pages: 768-769 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of Care

40 A 22-year-old nurse is working with a seriously ill 23-year-old patient who is recovering from a motor vehicle accident. The nurse recognizes having difficulty maintaining professional boundaries based on their similar ages. Which action should the nurse take initially? a. Seek guidance from another experienced nurse or the unit manager. b. Provide excellent care, but keep conversation and contact to a minimum. c. Arrange to have ancillary staff complete as much care as possible within their scope of practice. d. Discuss with the nursing supervisor the possibility of having another nurse assume this patient assignment.

A It may be challenging for the nurse to maintain professional boundaries when the age of the nurse and patient are near the same. It is advisable for the nurse to discuss the conflict with an experienced nurse or supervisor. Seeking reassignment from that patient is considered only after it becomes apparent that the issue cannot be effectively resolved. DIF: Cognitive Level: Application REF: Text Page: 769 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A patient diagnosed with amyotrophic lateral sclerosis says to the nurse, "I've been looking on the Internet to get more information about this disease. Which of the sites has the most reliable information?" Which site would the nurse recommend? a. National Institutes of Health (NIH) b. Food and Drug Administration (FDA) c. Centers for Disease Control and Prevention (CDC) d. Occupational Safety and Health Administration (OSHA)

A The NIH is a reputable and accurate website for obtaining health-related information. The CDC is appropriate for information about communicable diseases. OSHA oversees workplace safety, and the FDA oversees food and drug standards. DIF: Cognitive Level: Application REF: Text Page: 764 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care

38 An adolescent claims to have been physically abused by a parent. The adolescent's other parent angrily tells the nurse, "It's ridiculous for our child to accuse my spouse, who is a prominent doctor respected by the community." The nurse responds: a. "Do you believe that abuse does not exist in well-respected, professional families?" b. "I know that it is difficult to believe what your child is saying about your spouse, but abuse has occurred." c. "I know your spouse and I have never seen him be unkind or abusive to patients, but that is no proof of innocence." d. "Your spouse seems to have a very stressful, demanding practice. That can be a risk factor for losing one's temper when angry."

A The correct option effectively uses the therapeutic nursing communication of reflection. By reflecting back to the patient what she has said, the nurse assists the patient to view the statement in perspective. DIF: Cognitive Level: Application REF: Text Page: 738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 Which comment by the nurse would be most effective in teaching a patient about abusive behavior? a. "So when your husband says he needs other women because you aren't sexually satisfying his needs, do you believe what he is telling you is true?" b. "You say that your son has been pulling another child's hair and you are worried he's becoming violent and abusive like your brother?" c. "You say that you placed your son on an allowance but that you also want to regulate everything he spends and saves?" d. "I noticed that when your mother paid you a compliment about your new hairstyle, you seemed skeptical."

A The correct option is an illustration of how the nurse might help the patient to look at her husband's attempt to undermine her sexuality to inappropriately justify his infidelity. This is a form of sexual abuse. Questioning the son's behavior helps the patient to place fears (as yet unjustified by the patient's example) in perspective. The need to maintain control over the son's spending decisions describes a common parental error when first giving a child an allowance; the nurse will seek to clarify boundaries while remaining alert to the parent's attempts to maintain total control over all financial dealings of the child. Skepticism describes the patient's inability to acknowledge a parent's response as supportive. DIF: Cognitive Level: Application REF: Text Pages: 736-737 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 An individual who has been physically abused says, "When I called the police, I just wanted my spouse to stop shoving me around and kicking me. I didn't want anyone to get in trouble. It's easy to get angry with me because I spend too much money." Which comment by the nurse would be most therapeutic for this individual? a. "You feel your spouse was justified in the abuse because you overspent?" b. "Tell your spouse that if this happens again, I will report it to the police." c. "Your spouse abuses you when you overspend. So you think it will stop if you do not spend money?" d. "I can understand that you don't want to press charges, but your spouse needs help controlling anger."

A The correct option uses a therapeutic nursing communication to facilitate the victim of abuse to view the spouse's behavior in a more rational manner. Physical abuse is not excusable under any circumstances. DIF: Cognitive Level: Application REF: Text Page: 745 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 Which is the most appropriate initial action for a nurse when attempting to overcome personal negative attitudes about a patient who has a history of returning to an abusive spouse? a. Exploring own attitudes and values toward survivors of violence b. Identifying the dysfunctional behaviors exhibited by the violent family c. Concentrating on identifying any possible personal abusive relationships d. Attending seminars on the psychological impact of being the victim of abuse

A The first step toward effective intervention with survivors of family violence is the exploration of one's own attitude toward and knowledge about violence. DIF: Cognitive Level: Application REF: Text Pages: 737-738 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

40 A nurse enters the room of a patient newly diagnosed with multiple sclerosis and notes that the patient is crying quietly while lying in bed. Which communication by the nurse would be most appropriate? a. "You are crying. What are you feeling that's making you so sad?" b. "Do you want me to call the health care provider to order some antidepressant medication for you?" c. "I can understand why you would cry. I imagine most people would feel sad after being given your diagnosis." d. "Crying is a normal response to a diagnosis such as yours. You'll feel better after your plan of care has been fully developed."

A The most appropriate statement is the one that attempts to use therapeutic communication to determine whether the patient is depressed. The correct option is the only one that attempts to elicit more information about the patient's feelings. This would be the most effective means of assessing the patient's emotional status. DIF: Cognitive Level: Application REF: Text Pages: 764-765 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 When a nurse overhears the spouse of a patient threaten to "punch you in the face if you don't shut up" while sitting in the unit's dayroom, which action reflects the most immediate, therapeutic nursing intervention? a. Notify hospital security immediately that the situation exists. b. Tell the spouse, "Your presence is no longer permitted on the unit." c. Ask the patient if the spouse has ever engaged in abusive behavior. d. Tell the spouse, "The police will be called unless you leave immediately."

A The most therapeutic nursing intervention is to address the immediate threat of harm. By notifying hospital security the situation can be managed by individuals trained to do so effectively. DIF: Cognitive Level: Application REF: Text Page: 741 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

39 Which intervention will best establish a military personnel's mental health fitness for deployment to a war zone? a. Conducting a predeployment mental health screening as part of the general physical examination b. Reviewing the military performance records prior to deployment for identification of possible risk factors c. Providing each military personnel with the opportunity to confidentially discuss their individual concerns with a mental health professional d. Asking the military personnel to identify in writing any history of mental illness including depression, anxiety, or substance dependency issues

A The use of a predeployment mental health screening can reduce mental health problems, medical evacuations from war zones for mental health problems, and suicidal ideation. DIF: Cognitive Level: Analysis REF: Text Page: 757 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 Which statement made by a female military personnel currently deployed in a war zone provides the best evidence that the soldier is not feeling any unhealthy guilt over being separated from family? a. "My family back home realizes I miss and love them but leaving them was a part of my job." b. "When I get back, I will make up for the time I've been away from my family, especially my children." c. "The guilt I feel for leaving my family is offset by the pride they have for me serving my country like this." d. "Being away from my children and spouse is too hard to do again; when my enlistment is finished, I'm leaving the military."

A Women traditionally serve in the role of family matriarch. Following deployment, they may have a particularly difficult time adjusting to a new role including being separated from home, family, and children. This may cause feelings of guilt and inadequacy that can lead to depression and anxiety. The correct option demonstrates a healthy balance of concern and acceptance for and by the individual and her family. The remaining options lack that sense of balance. DIF: Cognitive Level: Analysis REF: Text Pages: 756-757 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

39 A military veteran is diagnosed with tinnitus. The educational material provided by the nurse related to the condition should include: (Select all that apply.) a. exposure to repeated loud noises is often the cause of the disorder. b. the primary characteristic is a persistent ringing in the ears. c. tinnitus may be either temporary or chronic. d. the symptoms can be expected to worsen over time. e. surgery on the eardrum is usually recommended.

A, B, C Hearing problems may develop as the result of traumatic injury or repeated exposure to noise hazards including gunfire, explosions, and loud equipment. Examples of hearing problems include partial or total hearing loss and tinnitus or ringing of the ears. Each of these may be temporary or permanent. The remaining options are not generally applied to tinnitus. DIF: Cognitive Level: Application REF: Text Page: 752 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

39 Female military personnel who have recently returned from deployment in a war zone are being assessed for potential physical and sexual assault as well as for an increased risk for developing posttraumatic stress disorder (PTSD). During the assessment, the nurse would ask: (Select all that apply.) a. "How safe did you feel while you were deployed?" b. "Did you have much contact with potential enemy soldiers?" c. "Have you ever experienced physical abuse as either a child or an adult? d. "Do you feel the military is prepared to help you reenter a noncombat environment?" e. "What is your greatest fear regarding your personal safety as a member of the military community?"

A, B, C The role of female soldiers has expanded into the realm of hostile environments. In the current military arena, nearly everyone is vulnerable to attack at any given time and female soldiers may even be singled out and targeted by enemy combatants. Women are more likely to suffer childhood abuse or other types of trauma compared to men. Survivors of multiple traumas may experience cumulative effects from re-victimization. These individuals may be less resilient and more vulnerable to develop psychiatric disorders including depression, PTSD, and other anxiety disorders. Questions related to their perception of military support or their safety in general is not related to assessing for the conditions mentioned. DIF: Cognitive Level: Analysis REF: Text Pages: 756-757 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 A military veteran is diagnosed with heart disease. With this medical history and a military background that included two tours of duty in a combat zone abroad, the nurse assesses for related psychiatric disorders by asking: (Select all that apply.) a. "When was the last time you accidentally hurt yourself?" b. "Have you ever experienced a migraine headache?" c. "Do you have problems falling asleep at inappropriate times?" d. "Can you describe your usual pattern of bowel elimination?" e. "Would you describe yourself as forgetful or absentminded?"

A, B, C, E Returning veterans may experience cognitive difficulties such as concentration problems and memory loss. Other complications can include sleep deprivation, migraine headaches, or insomnia. Poor concentration can also result in an increase in trauma from accidents. Constipation and diarrhea are not commonly associated with this population. DIF: Cognitive Level: Application REF: Text Page: 752 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

40 A patient has just been diagnosed with an inoperable brain tumor. Which patient statement about concerns should the nurse expect initially? a. "I wish I knew what I did to cause this to happen." b. "I'm very concerned about becoming a burden to my family." c. "If that is the case I would like to look into nursing home placement or hospice care right away." d. "Well, all of us have to die someday. I'll have to see a lawyer about a will, and I'll need you to tell me more about advance directives."

B Patients and families have concerns immediately after receiving a diagnosis of terminal illness. Concerns frequently include how long people live after diagnosis, emotional effect or inconvenience to family or friends, being a burden, financial concerns, suffering pain or disfigurement, feelings of loss of control, feelings of still having much to do in life, and dying alone. DIF: Cognitive Level: Application REF: Text Page: 765 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 Which interventions address the most commonly identified sources of risk to the mental health of military personnel and their dependents? (Select all that apply.) a. Depression support groups for adolescent dependents of military personnel b. Outpatient mental health services conveniently located near on-base housing c. Low-interest loans to assist dependent families in the payment of relocation expenses d. Relocation orders being delayed for families with school-age children so the move can occur during the summer months e. Access to on-base Internet communication resources to facilitate communication between deployed personnel and their families

A, B, D, E These five areas challenge the ability to provide mental health care to military personnel and their families: psychological health, access to services and support, communication challenges, deployment, and frequent relocation. While a stressor, financial aid is not a recognized mental health-related service the military provides. DIF: Cognitive Level: Analysis REF: Text Page: 757 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care

38 Which patient statements would be considered a potential risk factor for family-directed violence towards them? (Select all that apply.) a. "My parents certainly believed in not spoiling a child." b. "I'm angry that I had to get a part-time job to help buy food." c. "My family thinks I'm just a burden, but they'll be sorry that they treated me so badly." d. "When my spouse gets upset he tells me I'm no longer attractive because I've gained weight." e. "I work long hours to pay the bills and put food on the table but I can't seem to make my spouse happy."

A, C, D, E The correct options share a theme of fear, guilt, or failure. Anger would be a risk for abuse by the patient upon others. DIF: Cognitive Level: Analysis REF: Text Page: 748 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

40 Palliative care includes: (Select all that apply.) a. comfort measures. b. fluid-volume replacement. c. range-of-motion exercises. d. nasogastric tube feedings. e. pain medication therapies.

A, E Palliative care includes pain medications, stomach ulcer prevention, skin and mouth care, and other comfort measures. Palliative care does not necessarily include IV hydration (or tube feedings). There is no purpose for doing range-of-motion exercises for this patient. DIF: Cognitive Level: Comprehension REF: Text Pages: 765-766 TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment: Management of Care

39 Which assessment question is particularly important to ask of a veteran of the Iraq conflict? a. "Have you ever experienced a migraine headache?" b. "Could you ever see yourself considering suicide?" c. "Do you feel anxious when you find yourself in a confined space like an elevator?" d. "Would you say that your sleep patterns provide you with sufficient amounts of recuperative rest?"

B It has been estimated that as many as 20% of all suicides in this country are documented among veterans. In the first half of 2009, more American soldiers committed suicide than died in combat with continued high rates for veterans of Iraq and Afghanistan deployments. DIF: Cognitive Level: Application REF: Text Page: 756 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 Several nurses are newly assigned to a hospital unit that focuses on the care of military personnel who have sustained severe brain injuries and their families. The nurse manager would initially suggest that they: a. focus on honing their therapeutic communication and assessment skills. b. self-reflect concerning their feelings about working with the disabled. c. learn to recognize and act upon the emotional needs of the family. d. review the physical needs of the traumatic brain injured client.

B It is critical that providers working with survivors of trauma be aware of their personal feelings and vulnerabilities to provide quality clinical care. The remaining options are needs that can be addressed in the near future. DIF: Cognitive Level: Application REF: Text Page: 758 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

39 When educating an individual diagnosed with posttraumatic stress disorder (PTSD) regarding prescribed medication therapy, the nurse should include that: a. selective serotonin reuptake inhibitors (SSRIs) like escitalopram (Lexapro) have failed to prove effective in managing PTSD-related depression. b. the prescribed selective serotonin reuptake inhibitor (SNRI) venlafaxine (Effexor) is intended to help lessen intrusive thoughts. c. benzodiazepines like alprazolam (Xanax) are safe and have very good results in managing avoidance symptoms. d. mood stabilizers like valproic acid (Depakote) are effective in managing mood swings that occur with PTSD.

B Pharmacological interventions have been found to be useful in the treatment of the positive symptoms of PTSD including hyperarousal and reexperiencing phenomenon, and to a lesser extent the negative symptoms of PTSD, including avoidance symptoms. Selective serotonin reuptake inhibitors (SSRIs) are generally considered the first line of pharmacological treatment for individuals diagnosed with PTSD. These medications help with symptoms including depression, irritability, anxiety, and intrusive thoughts. The SNRI venlafaxine also has been found to be helpful in the management of this disorder. Benzodiazepines may be helpful in managing anxiety, insomnia, and hyperarousal, but they should be used cautiously due to the high degree of comorbid substance abuse in veterans. Mood stabilizers have not been demonstrated to be effective in the management of PTSD symptoms. DIF: Cognitive Level: Application REF: Text Pages: 754-755 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity: Pharmacological and Parenteral Therapies

40 A patient who is terminally ill expresses a wish to "hurry up and end it all." In exploring reasons for this wish, which should the nurse assess first? a. Guilt and fatigue b. Pain and depression c. Self-esteem and hope d. Competency and pain

B Studies have shown that when pain and depression are adequately treated, patient requests to hasten death diminish. DIF: Cognitive Level: Application REF: Text Page: 770 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

38 Which assessment finding most clearly indicates that a rape victim is exhibiting behavior typically seen in the acute stage of sexual assault? The victim: a. is demanding and controlling when dealing with staff. b. appears to be confused, restless, and fearful when left alone. c. uses profanity to describe events surrounding the attack. d. experiences a panic attack on the anniversary of the attack.

B The acute stage, immediately after the attack, is characterized by extreme confusion, fear, disorganization, and restlessness. Although many victims will be visibly upset, some may mask these feelings and appear to be outwardly calm or subdued. Overly assertive behavior and the use of profanity may or may not reflect the patient's ability to cope with the events. The panic attack months after the event describes the second stage of sexual assault, which involves long-term reorganization. DIF: Cognitive Level: Application REF: Text Pages: 747-748 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

40 An older adult patient diagnosed with Parkinson-induced dementia becomes critically ill with severe pneumonia. No family is available. After repeated failed attempts to contact the patient's agent designated by the Health Care Power of Attorney, which standard should the health care team use as the best method for decision making in planning care for this patient? a. Informed consent b. Best interests standard c. Patient's Bill of Rights d. Substituted judgment standard

B The best interests standard is applied when the patient lacks decisional capacity and no other designated health care proxy is available. This standard is based on what would promote the welfare of the "average" patient. DIF: Cognitive Level: Application REF: Text Page: 767 TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment: Management of Care

38 An Arab student new to an elementary school reports, "I don't want to go to gym class. It's never been a good class for me." Which factor would be of primary concern for a school nurse? a. The student's family's cultural beliefs regarding females interacting with males in public b. Complaints from others of "bullying" that occurs in gym class c. The student's problems adjusting to the new school environment d. A concern that the gym class is overcrowded and too competitive

B The child's complaint is vague. Although all the options are possible, the most common reason for a child to be resistant to a particular class relates to past experiences, such as having been a victim of bullying. This would be the most likely, and thus primary, concern. This option is the only one that reflects a safety issue. DIF: Cognitive Level: Analysis REF: Text Page: 741 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment: Management of Care

38 Which comment by the nurse would be most effective when using an empowerment model of intervention with an individual who has been abused? a. "You have left your spouse many times only to return. Please tell me how you view this last time as being different from all the times you left before." b. "Last time we talked, you thought your children would miss their father, but you now think they seem happier and almost relieved by your separation." c. "So you're having doubts and want to return to your husband even though you know that he broke your arm and caused your miscarriage?" d. "I support you returning to your spouse until you finally decide you have suffered enough.'"

B The correct option is a therapeutic reflection that helps the patient to sort out the fears that many victims of abuse have that their children will suffer without the other parent present. Commenting on a patient's history is sarcastic and nontherapeutic since it likely reflects the nurse's bias against the battered individual's ambivalence rather than viewing it as a normal part of the process that individuals who have been abused experience. DIF: Cognitive Level: Application REF: Text Page: 737 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 A patient with swelling and a laceration above the right eye states, "I don't know what caused me to fall and cut my head on the door frame." The patient's spouse appears nervous but smiles when mentioning that the patient is "so clumsy at times." The nurse should give priority attention to which intervention when addressing this patient's needs? a. Directly asking the patient if spousal abuse is occurring or has ever occurred b. Completing a thorough assessment that includes a focus on signs of old injuries c. Interviewing the patient regarding the circumstances surrounding this suspicious fall d. Notifying security that there is a possibility that this patient is a victim of physical abuse

B The correct option reflects the nurse's appropriate attention to the determination of any physical indications that physical abuse may have occurred (Maslow's Hierarchy). The remaining options do not address this priority but rather focus on the emotional aspect of the situation. DIF: Cognitive Level: Application REF: Text Pages: 738-739 TOP: Nursing Process: Assessment MSC: NCLEX: Safe, Effective Care Environment: Management of Care

40 The adult child of a critically ill patient has been keeping vigil, remaining at the bedside constantly for 3 days. Which communication from the nurse would be most appropriate when the child becomes demanding and impatient with the staff providing the parent's care? a. "I can see that you are feeling short-tempered, which is not unusual under the circumstances. Still, it is not good for your parent to hear you complaining." b. "It must be difficult for you to be here day after day. What other family members can stay so that you can get a good night's sleep at home?" c. "It would be best for you to go home for a few days and get some sleep and proper nutrition. Do you have the number here so you can call if you feel the need to?" d. "You have had little sleep in the last few days. Perhaps you should go home for some rest. You can't be of much help if you are so tired you can't think properly."

B The correct response is one that acknowledges the family member's situation and then explores an alternative. DIF: Cognitive Level: Application REF: Text Page: 765 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 A young, newly married adult says, "My spouse never lets me out of sight. I'm not allowed to do anything on my own, and I'm constantly accused of cheating." Which nursing comment is most therapeutic for this individual? a. "Have you discussed the behavior with your spouse?" b. "How does your spouse's behavior make you feel?" c. "Are there other examples of controlling behaviors on your spouse's part?" d. "Do you feel that your spouse has anything to be upset or suspicious about?"

B The most therapeutic communication is the one that facilitates the patient's expression of feelings. DIF: Cognitive Level: Application REF: Text Page: 748 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

39 A military veteran being treated for substance abuse shares that the family is experiencing financial problems since being discharged. In order to assess the individual's coping skills, the nurse asks: a. "Do you have any idea about how your finances got out of your control?" b. "How well were you at managing your finances before leaving the military?" c. "Can you give me some idea of the kind of financial help you feel you need?" d. "Have your financial expenses increased dramatically since being discharged?"

B The nurse must be mindful that substance abuse is a disease and individuals may return to previous ways when coping with stressful and unplanned events. Assessing previous coping skills will provide insight into the way current stresses will be managed. The remaining options provide opportunities to assess the financial problem itself. DIF: Cognitive Level: Application REF: Text Page: 756 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

38 A person currently in an abusive relationship tells a nurse, "My partner is really sorry for hitting me and wants to come back and be part of the family again." The nurse should provide which intervention? a. Share with the patient that abusers seldom voluntarily stop abusing. b. Encourage the patient to demand the abuser seek psychiatric help. c. Advise the patient to focus on minimizing the abuse if the relationship continues. d. Inform the partner that any physical abuse will certainly be reported to the police.

B There are community groups that help abusive individuals relearn coping mechanisms that are appropriate. This option is the only one that provides an appropriate, therapeutic intervention. DIF: Cognitive Level: Application REF: Text Page: 738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A patient underwent surgery for cancer and now needs follow-up chemotherapy. The patient reports anorexia, fatigue, and trouble concentrating and sleeping. A nurse would place highest priority on responding to which statement by the family member? a. "We are so concerned about him. He hardly eats or sleeps anymore. Can something be done?" b. "We're not surprised he's depressed after all he is going through, but is there some medicine that can help him right now?" c. "We're not surprised he's so depressed. It ought to be expected after all that he's been through. He'll be back to normal after the chemotherapy." d. "We can't wait for the chemotherapy to start. He worries about any remaining cancer starting to grow between the surgery and the chemotherapy."

C A persistent myth proposes that if a person "has a reason" to be depressed, no treatment is needed because this "functional depression" is a normal response. However, this myth denies that the patient has a need for effective treatment. For this reason, the nurse should first follow up on that response. DIF: Cognitive Level: Analysis REF: Text Page: 764 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

40 The adult child of a terminally ill patient tells a nurse, "The doctor recommended considering end-of-life care." The nurse interprets that this most likely means that the patient will not live more than _____ month(s). a. 1 b. 3 c. 6 d. 24

C End of life is generally accepted as the probable last 6 months of life. DIF: Cognitive Level: Comprehension REF: Text Pages: 766-767 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

40 When the parents of a terminally ill teenager whose death is imminent are approached and counseled regarding the possibility of organ donation, the parents refuse. The nurse is concerned that they may not have fully considered the positive effect organ donation has on both the surviving family members as well as organ recipients. Which nursing action will have the greatest therapeutic effect regarding the parents' decision? a. Ask the chaplain to address the issue with the parents after giving them time to reconsider. b. Gently share with the parents that they could be making a mistake they will later regret. c. Say nothing, and support the parents in their decision to the fullest extent possible. d. Refer the matter to the hospital's organ procurement agent.

C Even when a nurse finds it difficult to accept an informed decision a parent has made, professional ethics clearly require that the decision be supported. DIF: Cognitive Level: Application REF: Text Page: 770 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A patient with metastasized cancer says to the nurse, "I've been reading about some of the cancer research, and I am still hoping for a cure in the next few months." In formulating a response to the patient, which should the nurse consider first? a. The patient's religion and/or faith-based beliefs b. The need for a consultation with a professional grief counselor c. The purpose that would be served in confronting the patient's denial d. The patient's ability to understand the meaning of this particular research

C Having "hope against hope" may not mean that the patient is in denial, but rather that he or she is using denial as an adaptive defense mechanism. The nurse should first consider what purpose confrontation would serve at this time. DIF: Cognitive Level: Analysis REF: Text Page: 767 | Text Page: 770 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

38 What is the best initial approach for a nurse when managing the care of an individual with two children who works full-time and has been abused by a partner? a. Teach the individual how to avoid provoking the abuser. b. Assist the individual in filing a police report describing the abuse. c. Help the individual identify needs to best obtain the appropriate support. d. Facilitate the individual's move into a safe house located near the current workplace.

C In order to best provide support, the nurse must fully understand the patient's needs. This is done before support options can be determined. The other options are examples of interventions for needs that have not yet been determined. DIF: Cognitive Level: Application REF: Text Page: 736 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

39 The nurse is about to assess the possible incidence of sexual abuse. Based on an understanding of how males and females experience and internalize sexual trauma differently, the nurse would ask the male soldier: a. "Have you ever been sexually abused?" b. "Have you ever felt victimized sexually by anyone?" c. "Has an unwanted sexual advance by anyone ever made you feel harassed or confused?" d. "Has a superior officer ever made an unwanted sexual advancement that you felt you had to agree to?"

C Males and females may experience sexual trauma in different ways. Males typically do not view themselves as being potential victims of sexual abuse and are not likely to admit to being a victim of sexual abuse. They may therefore experience it as a narcissistic insult, causing confusion and even questioning their masculinity or sexual preference. Asking the question in this context is a more effective questioning technique. DIF: Cognitive Level: Analysis REF: Text Page: 756 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 Six months after returning from a combat zone, a discharged Marine reports having both memory and concentration problems that resulted in earning failing grades in two college courses. An understanding of the pathophysiology of traumatic brain injury would prompt the nurse to initially ask: a. "Were you ever treated for a traumatic brain injury?" b. "Were you ever hit on the head during your military deployment?" c. "Has a blow to the head ever resulted in you being unconscious for more than 20 minutes?" d. "When did the memory problems and difficulty with concentration begin to affect your schoolwork?"

C Many cases of traumatic brain injury (TBI) may be overlooked as the symptoms are diffuse and may not initially suggest any specific brain injury as the primary cause. Often symptoms do not surface until well after the initial injury, which can further complicate accurate diagnosis of TBI. Also, mild TBI may not be the primary or most urgent injury that occurs in the field, and it may be missed during triage. The question of whether the individual has ever experienced a blow to the head that resulted in unconsciousness lasting 20 minutes or more would be the most probative question to ask. DIF: Cognitive Level: Analysis REF: Text Pages: 752-754 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

39 A member of the military shares that he has been a victim of sexual trauma during his enlistment. Which question will the nurse ask to best assess the individual's degree of self-blame? a. "Were you physically hurt as a result of sexual abuse?" b. "Have you confided this information with family or a trusted friend?" c. "What occurred when you reported the attack to your military superior?" d. "Have you been tested for sexually transmitted diseases since the attack?"

C Military sexual trauma (MST) survivors may experience self-blame and doubt, and even have feelings of guilt that they somehow brought on the assault. This situation can result in an emotional invalidation of their traumatic experience when they report these incidents to superiors, only to be discouraged from following up on their claim or told that the abuse never happened. Having their report taken seriously and resulting in appropriate actions has a positive bearing on the victim's sense of validation. The remaining options lack the opportunity to open up discussion on that topic. DIF: Cognitive Level: Analysis REF: Text Page: 756 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

38 Which statement best indicates use and abuse of power in a violent family situation? a. "I admit I was mad and yelling and swinging my fists in the air, but I wasn't trying to hit our child. I was letting off some steam. My spouse just overreacted." b. "When she found out I watched television instead of taking the kids to the park, she starting yelling about how I don't care about the kids. She has no right to get mad at me. I should have some time to myself." c. "I thought he would like this new recipe. I should have known better. I will not do that again. He was right. He works all day and should come home to a good meal that he can enjoy. It's not too much to ask of a wife." d. "All I did was tell him I need some money. I can't understand why he can't just give me what I need. I stay home and take care of his house and kids, and I have to almost beg before he gives me money to spend on myself."

C The correct option shows clear indication that the husband has power over his wife as she expresses agreement with his expectations and indicates she "should know better." The other options are examples of individuals feeling victimized and partners who are able to leave or participate in the situation without becoming victims. DIF: Cognitive Level: Application REF: Text Page: 736 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

39 Which information noted on a psychosocial assessment is of greatest concern when identifying risk factors for the possible development of posttraumatic stress disorder (PTSD) for a soldier about to be deployed to a war zone? a. A parent has been diagnosed with severe and persistent anxiety b. The soldier had an extended tour of duty in a war zone previously c. As a child the soldier survived a major hurricane that killed a sibling d. The spouse has suggested that their relationship may not survive this separation

C There is evidence that the potential to develop PTSD may be influenced by earlier life experience such as the exposure to a traumatic experience as a child. While the other options suggest stressors, they are not as personally impactful or as traumatic as the correct option. DIF: Cognitive Level: Analysis REF: Text Page: 753 TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

38 Which intervention would be the best initial approach for a nurse to take when a young adult patient is verbally abusive? a. Ask the patient to define "verbally abusive language." b. Provide the patient with examples of assertive communication. c. Identify the patient's verbal abuse in order to set standards for future dialogue. d. Remove privileges from the patient until communications show less aggression.

C This question asks that behaviors for intervention be prioritized. First, it is necessary to help the patient identify the problem and to set criteria for future communications. DIF: Cognitive Level: Application REF: Text Page: 739 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

39 A military veteran is being evaluated for traumatic brain injury (TBI). Which nursing assessment data supports such a diagnosis? (Select all that apply.) a. Baseline blood pressure is 148/96 b. Has been treated for bronchitis twice in the last 8 months c. Patient reports experiencing an average of 3 headaches per week d. Petit mall seizure activity well controlled with antiseizure medication therapy e. Patient reports a weight gain of 15 pounds since returning from deployment 12 months ago.

C, D, E Physiological problems related to TBI can include headache, seizures, as well as appetite and weight changes. The remaining options, hypertension and respiratory infections, are not generally occasioned with TBI. DIF: Cognitive Level: Analysis REF: Text Pages: 752-753 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

40 A nurse is caring for a patient awaiting test results that will indicate whether the patient has cancer. Which communication would be most helpful initially to facilitate a therapeutic nurse-patient relationship? a. "I'm sure this must be a difficult time. It may be most helpful for you to focus on the development of new drugs and other therapies." b. "How sad and frightened you must feel right now. Do you have any family or friends that are good support systems for you that I might call?" c. "I am trying to imagine how you feel. If you spend this time making sure all your affairs are in order, it will give you more of a sense of control over the situation." d. "This is a time of uncertainty for you and your family. I sense that you are quite anxious and in disbelief. I'd like to talk to you about how you're feeling."

D Between the development of symptoms and a definitive diagnosis, patients and their family members or loved ones have to endure a time of uncertainty. Often the best way to begin the intervention is to tell the person the behavior or emotion that you are observing and give it a name (shock, disbelief, fear, or sadness). It is important to validate and seek the person's agreement with or refinement of this perception. The correct response "offers self," a therapeutic communication technique. DIF: Cognitive Level: Application REF: Text Page: 764 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 An individual whose boyfriend raped her tells the nurse, "It's no use reporting it. Everyone knows I've been sexually intimate with him many times before." The nurse's initial response should be: a. "It's not your fault. He needs to get help controlling his anger." b. "You will need to talk to someone. Do you have a best friend to talk to?" c. "The police need to be aware that your boyfriend is willing to act this way when he's angry." d. "If you said 'no,' your boyfriend needs to respect your wishes. He needs help so this will never happen again."

D Contrary to some thinking, if a person says "no," the partner is responsible for respecting and complying with the request. Violence counseling is appropriate for both individuals in order to stress the importance of communication and respect between sexual partners. DIF: Cognitive Level: Application REF: Text Page: 747 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A nurse should use which measure initially to reduce dyspnea in a patient with end-stage chronic obstructive pulmonary disease? a. Administer a dose of an ordered prn bronchodilator. b. Encourage the patient to use an incentive spirometer. c. Assist the patient to cough and deep breathe. d. Elevate the head of the bed.

D Dyspnea occurs in many chronic and end-stage diseases and the nurse can assist the patient with shortness of breath by raising the head of the bed to a comfortable position. Bronchodilators may be used as an aid, but positioning is noninvasive and is a first-line intervention. Incentive spirometry, coughing, and deep breathing would prevent atelectasis but would not treat the symptom of dyspnea resulting from the end-stage disease process. DIF: Cognitive Level: Application REF: Text Page: 766 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

38 Which behavior would the nurse expect in a person who commits psychic rape? The perpetrator: a. gives money to the victim after the rape. b. seduces the victim by providing wine, flowers, and music. c. threatens the victim to submit or else be severely beaten. d. always mentions including violent bondage in sexual activities.

D Psychic rape involves an assault on the victim's dignity and self-respect. Examples include verbal assault, street harassment, pornography in the media, and portrayals of violent sex. Giving money after rape describes an economic partnership. Gift giving describes a seduction rape. Threats describe a fear rape. DIF: Cognitive Level: Application REF: Text Page: 747 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

40 A nurse working in the pediatric intensive care unit is assigned to pediatric patients who are experiencing pain. The nurse would select the Wong FACES Pain Rating Scale for use in which child? a. A 6-month-old patient with failure to thrive b. A 12-month-old patient with a burn injury c. A 24-month-old patient with injuries after a fall d. A 38-month-old patient with sickle cell disease

D The Wong FACES Pain Rating Scale can be used for children ages 3 years (36 months) and above. The patient is asked to point to the face that best describes the pain, from a smiley face to a tearful one. DIF: Cognitive Level: Application REF: Text Pages: 765-766 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

38 A nursing colleague says, "This patient was admitted claiming to have been raped by her boyfriend, but just look at the sexy clothes she's wearing." Which response reflects an understanding of the most likely source of the colleague's comment? a. "Have you ever cared for other sexual assault victims?" b. "Your sister was raped when she was in college, wasn't she?" c. "You have three unmarried brothers about the patient's age, don't you?" d. "Are you saying that wearing sexy clothes caused her to be sexually assaulted?"

D The correct option is the most professional response to a colleague who shows evidence of a bias. Although most nurses do not actually blame survivors for what has happened to them, research reveals that they are less tolerant of certain behaviors, such as going out late at night, not locking car doors, wearing provocative clothing, or not resisting the assault "enough." The first step in providing effective nursing care in this situation is exploring one's own attitudes toward victims of this crime. DIF: Cognitive Level: Analysis REF: Text Pages: 737-738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

38 Which comment best reflects the nurse's use of an empowerment model with an individual who has been abused? a. "Let me share with you my knowledge of what happens psychologically to individuals who have been abused." b. "I know that you feel that your partner will change, but the current research does not validate your thinking." c. "It's up to you to end the violence. You are the only one who can set limits on how your partner is allowed to treat you." d. "Let's consider what you believe your options are in terms of your relationship with your partner in light of the behavior toward you."

D The correct option uses an empowerment model by assuming mutuality in sharing and providing respect for what the survivor knows. DIF: Cognitive Level: Application REF: Text Pages: 737-738 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

39 A combat experienced military veteran with a diagnosis of depression is concerned about adjusting to civilian life and reconnecting with family and friends. In assisting the individual's long-term readjustment, the mental health nurse would suggest a referral to: a. job retraining programs. b. family and marital counseling sessions. c. civilian employment assistance services. d. support groups comprised of combat veterans.

D Upon returning home the combat veteran finds that he no longer has the psychological and emotional support of his comrades in arms. He finds little solace from family and friends who cannot share his experiences and often has difficulty assimilating to his previous life. A support group comprised of fellow military personnel would be the most positive form of assistance to provide long-term positive readjustment to civilian life. DIF: Cognitive Level: Analysis REF: Text Pages: 757-758 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity: Management of Care