UDC II: Psych Ad.Q

Which behavior is characteristic of panic during a crisis? A. Being physically immobile B. Sobbing for no apparent reason C. Difficulties with falling asleep D. Startling to loud noises and touch

Answer: A Being unable to physically move is a psychomotor characteristic of extreme panic during a crisis. Sobbing, difficulties with sleep, and startling are associated with lower levels of anxiety.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), which behaviors describe an individual with a cluster A personality disorder? A. Odd and eccentric B. Anxious and fearful C. Dramatic and erratic D. Hostile and impulsive

Answer: A Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.

According to Peplau's model of the nurse-client relationship, in which phase will most of the client's problem solving occur? A. Working phase B. Preorientation phase C. Orientation phase D. Termination phase

Answer: A During the working phase, goals are met, problems are resolved, and changes in behavior occur. In the preorientation phase, the nurse prepares for the orientation phase. During the orientation phase, trust is the primary focus, goals and contracts are set, and problems are identified. During the termination phase, the nurse and client review accomplishments, reinforce the use of new behaviors, and close the relationship.

Which condition would be a contraindication to electroconvulsive therapy (ECT)? A. Brain tumor B. Type 1 diabetes C. Hypothyroid disorder D. Urinary tract infection

Answer: A ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroidism, or urinary tract infection.

Which primary feeling would the nurse anticipate that clients with bulimia nervosa experience after an episode of bingeing? A. Guilt B. Paranoia C. Euphoria D. Satisfaction

Answer: A Guilt is a primary feeling clients experience after a bingeing episode. A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with schizophrenia and paranoid personality disorder, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels guilt rather than euphoria or satisfaction because these clients are aware that the eating pattern is abnormal.

Which intervention is most important when helping clients resolve a crisis situation? A. Encouraging socialization B. Meeting dependency needs C. Supporting coping behaviors D. Suggesting a therapy group

Answer: A In a crisis, the individual often just needs support to regroup and reestablish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. People who are experiencing crisis may have difficulty working in a therapy group. After stabilization occurs, an individual may benefit from sharing common experiences with others.

Which principle guides the nurse's role in the maintenance or promotion of the health of older adults? A. There is a strong correlation between successful retirement and good health. B. Thoughts of impending death are common and depressing to most older adults. C. Some of the physiological changes that occur as a result of aging are reversible. D. Older adults can better accept the dependent state that chronic illness often causes.

Answer: A Individuals who can reflect on life and accept it for what it was and who are able to adjust and enjoy the changes retirement brings are less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

While caring for an older adult client, which symptom would require an immediate reassessment of the client's needs and plan of care? A. Memory loss or confusion B. Neglect of self-care C. Increased daily fatigue D. Withdrawal from usual activities

Answer: A Memory loss or confusion would require an immediate reassessment. All are common signs of depression due to the aging process; however, memory loss or confusion requires immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention. Although neglect of self-care can occur, it is not the immediate need. Although increased daily fatigue is important, it does not require immediate follow-up. It is common for clients with depression to withdraw from usual activities, so it does not need immediate reassessment.

Which initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day? A. "I see that you're worried. We're using medication to ease your wife's discomfort." B. "This is expected. I suggest that you go home because there's nothing you can do to help." C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification." D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."

Answer: A Recognizing the spouse's feelings and explaining therapy help decrease his anxiety. Saying that there is nothing he can do discourages verbalization of concerns and promotes feelings of isolation and helplessness. Talking about death is inappropriate and increases fears. Pain is the client's subjective experience and the nurse would avoid giving false reassurance.

Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? A. Safety within the environment B. Enhancement of psychological faculties C. Participation in educational activities D. Face-to-face contact with other clients

Answer: A Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.

The CAGE questionnaire is used to screen the client's use of which substance? A. Alcohol B. Barbiturates C. Hallucinogens D. Multiple drugs

Answer: A The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words (Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship? A. The self and a desire to help B. Knowledge of psychopathology C. Advanced communication skills D. Years of experience in psychiatric nursing

Answer: A The nurse brings an understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model and contribute to quality of care, but these are secondary to the offering of self and the fundamentals of good communication.

The nurse manager notices that a previously effective nurse appears to be distracted, forgets to document, and rarely completes the workload. Which response would the nurse manager use? A. "Your workflow is usually great, but now you seem distracted. What's going on?" B. "Why are you are so distracted and forgetful? I need to know what's going on." C. "Go ahead and take a break and then come to my office so that we can talk." D. "I've noticed that your performance has slipped. Are you using drugs or alcohol?"

Answer: A The nurse manager starts with an understanding and supportive approach to help the individual self-identify ("What's going on?") and address the problem. "Why" questions are usually avoided, and this particular why question sounds accusatory. Taking a break after the discussion would be more helpful to the nurse if intense emotional content is disclosed. Changes in performance can be associated with substance abuse, but at this point there is insufficient evidence.

Which prescribed treatment would a nurse anticipate for a client with severe, persistent, intractable depression and suicidal ideation? A. Electroconvulsive therapy B. Short-term psychoanalysis C. Nondirective psychotherapy D. High doses of anxiolytic medications

Answer: A The nurse would anticipate electroconvulsive therapy. Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that do not respond to antidepressant medication. The client's depressed mood limits participation in psychoanalysis, which is usually long term; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy should be directed, not nondirective, toward helping the client learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Nondirective psychotherapy would be ineffective. Antianxiety medications (anxiolytic medications) are usually not prescribed for clients with depression.

Which consistent approach would the nurse use for a client with an antisocial personality disorder? A. Warm and firm without being punitive B. Indifferent and detached but nonjudgmental C. Conditionally acquiescent to client demands D. Clearly communicative of personal disapproval

Answer: A The nurse would be warm and firm without being punitive. The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

Which response would the nurse make to a client with an obsessive-compulsive disorder who on the day of a job interview begins to display compulsive behavior? A. "Going for your interview must be upsetting you. Describe what you're feeling now." B. "It's important for you to overcome your anxiety. You should keep that appointment." C. "Your actions indicate that you want to delay the interview. Do you really want the job?" D. "This interview seems to upset you. Do you think you should look for another kind of job?"

Answer: A The nurse would say, "Going for your interview must be upsetting you. Describe what you're feeling now." The client's behaviors are a defense against anxiety resulting from having to make decisions, which triggers old fears; the client needs support. Noting that it is important for the client to overcome the anxiety and encouraging the client to keep the appointment denies the client's overwhelming anxiety and shows a lack of realistic support. Asking whether the client really wants the job is judgmental; an increase in anxiety does not necessarily mean that the client does not want to attain the goal. The client should be encouraged to work through symptoms, not to avoid risk by looking for another kind of job.

Which action for nutritional needs would the nurse take for a depressed client who has been sitting alone in a chair most of the day and displays no interest in eating? A. Stay with the client during meals. B. Take the client to the dining room. C. Bring the client a tray of finger foods. D. Talk with the client about the importance of nutrition.

Answer: A The nurse would stay with the client during meals. Active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat. Finger foods are more effectively given to clients experiencing mania. Discussing the importance of nutrition is too passive an intervention for a depressed client and usually will not stimulate the client to eat.

Which action by the nurse would decrease the risk of injury for a child with oppositional defiant disorder? A. Redirect anger in other ways. B. Assess problem-solving skills. C. Explore home support systems. D. Determine the presence of substance abuse.

Answer: A The nurse would work with the child to learn how to take control of, take responsibility for, and redirect their angry outbursts. Problem-solving skills and presence of substance abuse would be assessed in children with conduct disorders. Home support systems would be explored for children with intermittent explosive disorders.

An older adult says, "I regret so many of the choices I've made during my life." According to Erikson's psychosocial stages of development, which developmental conflict has the client failed to accomplish? A. Ego integrity versus despair B. Identity versus role confusion C. Generativity versus stagnation D. Autonomy versus shame and doubt

Answer: A The sense of ego integrity comes from satisfaction with life and acceptance of what has been and what is. Despair reflects guilt or remorse over what might have been. During puberty adolescents attempt to find themselves and integrate their own values with those of society; an inability to solve conflict results in confusion and hinders mastery of future roles. During early and middle adulthood the individual is concerned with the ability to produce and to care for that which is produced or created; failure during this stage leads to self-absorption or stagnation. Autonomy, the ability to control the body and environment, is developed during the toddler period; doubt may result when the child is made to feel ashamed or embarrassed.

Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? A. Sets limits B. Has variety C. Is group oriented D. Allows freedom of expression

Answer: A The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.

A woman accompanied by three young children says that she is seeking help in leaving her husband. He has beaten her for years and has recently started hitting the children. Which action would the nurse take first? A. Arrange for a staff member to watch the children so the mother and nurse can talk. B. Call a facility where the mother and her children will be safe until the crisis is resolved. C. Assess for ambivalence about the decision to leave before making permanent plans. D. Suggest that the husband and wife make an appointment for couples counseling.

Answer: A This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, an action plan can be developed. A safe facility, the client's ambivalence, and couples counseling might be discussed after assessment of the situation.

Which statement demonstrates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship? A. "My clients and I are partners in the planning that helps meet their physical and mental health needs." B. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." C. "Mental health is achieved and maintained when the nurses and the clients exhibit respect and caring for each other." D. "Without a mutually satisfying relationship between nurse and client, achieving mental and physical wellness is very difficult."

Answer: A Today's nurse-client relationship is a partnership that includes the nurse's clinical competence and the client's right to self-determination in decision-making. The development of a true therapeutic relationship is a goal, but when that is not achievable, nursing care is still be provided. Mutual respect and caring are basic elements, but many other factors also have an effect on mental health A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client. If that is not achievable, nursing care is provided to help the client maximize potential in physical and mental health.

According to Erikson's psychosocial stages of development, mastery of which task increases a child's ability to cope with separation or pending separation from significant others? A. Trust B. Identity C. Initiative D. Autonomy

Answer: A Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.

Which response is therapeutic for a client who says, "The world is filled with terrible people. Why couldn't one of them get HIV [human immunodeficiency virus] instead of me"? A. "It seems unfair that you should have this disease." B. "I'm sure you really don't wish this on someone else." C. "Maybe you should speak with your religious leader." D. "You can get treatment; HIV is considered a chronic illness."

Answer: A The nurse reflects feelings of unfairness and this encourages the client to express feelings. The nurse avoids judgmental responses (don't wish this) that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings or offense. People with newly diagnosed chronic illnesses grieve for their loss of health and should be assisted through the stages of grief.

A client who has alcoholism becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms is the client using? Select all that apply. One, some, or all responses may be correct. A. Projection B. Suppression C. Sublimation D. Identification E. Rationalization

Answer: A & E Clients with alcoholism commonly use projection and rationalization to make reality more acceptable. Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. Rationalization is making acceptable excuses for undesirable behavior. Suppression, sublimation, and identification are not commonly used by clients with an alcohol problem. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious. Sublimation is the rechanneling of anxiety into constructive activities. Identification is the unconscious wish to be like another person.

Which factors would the nurse find in the client history of a young college student with borderline personality disorder? Select all that apply. One, some, or all responses may be correct. A. Impulsiveness B. Lability of mood C. Ritualistic behavior D. Psychomotor retardation E. Self-destructive behavior

Answer: A, B, E Impulsiveness, lability of mood, and self-destructive behavior are all characteristics of a borderline personality disorder. Clients with borderline personality disorder often lead complex, chaotic lives because of their inability to control or limit impulses. Extremes of emotions, ranging from apathy and boredom to anger, may be displayed within short periods. Impulsive self-destructive acts such as reckless driving, spending money, and engaging in unsafe sex often result in negative consequences. Ritualistic behavior is associated with obsessive-compulsive disorders. Psychomotor retardation is associated with mood disorders such as depression.

Which substance is considered addictive in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)? Select all that apply. One, some, or all responses may be correct. A. Alcohol B. Caffeine C. Cannabis D. Gambling E. Hallucinogens F. Antianxiety medications

Answer: All of them Alcohol, caffeine, cannabis, hallucinogens, and antianxiety medications are all considered substances of abuse in the DSM-5. Tobacco, opioids, inhalants, sedatives, hypnotics, and stimulants are also listed. Behaviors are gradually being recognized as addictive. For example, gambling was officially declared a disorder in 2013.

Which type of group is Alcoholics Anonymous (AA)? A. Social group B. Self-help group C. Resocialization group D. Psychotherapeutic group

Answer: B AA is a self-help group of people who meet to attain and maintain sobriety. A social group centers on building interpersonal relationships through participation in mutual activities. A resocialization group centers on increasing social skills that may be diminished or lacking. A psychotherapeutic group treats mental and emotional disorders with the use of psychological techniques and always has a member of the health care profession as its leader.

At which point in the daily routine do clients who experience alterations in perception tend to have more problems with vivid hallucinations? A. Before meals B. After going to bed C. During group activities D. While watching television

Answer: B After going to bed, auditory hallucinations are most troublesome because environmental stimuli are diminished and there are few competing distractions. Meals, group activities, and television provide relatively high and competing environmental stimuli.

The client can no longer recognize familiar objects such as his glasses and toothbrush. Which term describes these assessment findings? A. Apraxia B. Agnosia C. Aphasia D. Amnesia

Answer: B Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the body. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or properly putting on clothing. Aphasia is the term for the loss of language ability; loss is usually progressive. Amnesia is the term for the impairment of memory both recent and remote.

Which description is correct for Alzheimer disease? A. Emerges in the fourth decade of life B. Is a slow, relentless deterioration of the mind C. Is functional in origin and occurs in the later years D. Is diagnosed through laboratory and psychological tests

Answer: B Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. Diagnostic tools, such as computed tomography scan or positron emission tomography, are used to rule out conditions (e.g., neoplasms), and psychological tests such as the Mini-Mental State Examination are used to determine cognitive decline; however, there are no tests that give a definite confirmation of Alzheimer disease.

In the acute phase of bipolar disorder, manic episode, which biopsychosocial need is the priority? A. Psychological B. Physical C. Intellectual D. Relational

Answer: B During a manic episode, the excessive hyperactivity increases the risk for cardiac collapse, dehydration, nutritional deficiencies, and sleep pattern disruption. The client also has increased risk for physical injury secondary to poor judgment and impulsiveness. The other needs are also important, but during the acute manic phase, it is difficult for the client and the health care team to work on topics that require focus and concentration.

Which speech pattern is a disturbed client displaying when she or he starts to repeat phrases that others have just said? A. Alogia B. Echolalia C. Neologism D. Symbolic speech

Answer: B Echolalia is repetition of another person's remarks, words, or statements. It occurs when individuals are fearful of saying their own words and echo the words of others. Alogia is limited speech. Neologism is when new words are coined or old words take on private symbolic meanings. Symbolic speech is use of symbols to replace direct communication.

When the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied? A. Planning B. Evaluation C. Assessment D. Implementation

Answer: B Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.

Which intervention would the nurse use when 2 female clients are found together in bed having sexual relations? A. Ask the health care provider to transfer one of the clients to another unit. B. Adopt a matter-of-fact, nonjudgmental attitude and set limits on the behavior for several days. C. Separate them whenever possible throughout the day and always at night. D. Limit their privileges because their behavior is undesirable.

Answer: B Everyone has the right to his or her sexual orientation and preferences, but limits must be set for behavior in a psychiatric unit. Helping clients deal with their sexuality is therapeutic; if the staff always takes control by transferring clients or separating them, the opportunity to learn socially acceptable behavior is lost. Punishing clients is never therapeutic.

Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? A. Lack of interest in family and others B. Reliving the trauma in dreams and flashbacks C. Avoidance of situations that resemble the stress D. Blunted affect when discussing the traumatic situation

Answer: B Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.

Which intervention would the nurse include when planning continuing care for a moderately depressed client? A. Encourage the client to determine four leisure-time activities. B. Offer the client the opportunity to decide on wearing a green or blue shirt. C. Relieve the client of the responsibility of making any decisions. D. Allow the client time to be alone to decide in which activities to engage.

Answer: B For a moderately depressed client, the nurse would offer the client the opportunity to make a decision to wear a green or blue shirt. Allowing the client to make decisions that can be handled helps improve confidence. The client is depressed, and asking the client to determine four leisure-time activities can result in total inactivity. Relieving the client of the responsibility of making any decisions will demoralize a client who is only moderately depressed. Allowing time for the client to be alone to decide in which activities to engage would be overwhelming for a moderately depressed client; this decision allows too many options.

Which type of sexual disorder describes a client who has a sexual obsession with shoes? Select all that apply. One, some, or all responses may be correct. A. Sexual sadism B. Fetishistic C. Pedophilic D. Voyeuristic E. Frotteuristic F. Exhibitionistic

Answer: B Having a fetish is to become sexually aroused by something that would not be typically arousing. A fetishistic disorder is characterized by a sexual focus on objects (such as shoes, gloves, pantyhose, and stockings) that are intimately associated with the human body. Sadism is achievement of sexual satisfaction from the physical or psychological suffering (including humiliation) of a victim. Pedophilic disorder is a predominant or exclusive sexual interest toward prepubescent children. Voyeurism is characterized by seeking sexual arousal through the viewing (usually secret) of other people engaged in intimate situations. Rubbing or touching a non-consenting person is frotteuristic disorder. Exhibitionistic disorder involves the intentional display of the genitals in a public place.

For a hyperactive, manic client who exhibits flight of ideas, which rationale explains why the client is not eating? A. Feels undeserving of the food B. Is too busy to take time to eat C. Wishes to avoid others in the dining area D. Believes that the food is poisoned

Answer: B Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

Which intervention would the nurse use when the roommate reports that the client is masturbating at night and demands another room? A. Move the roommate who made the report to another room. B. Provide the client who is masturbating with periods of private time. C. Tell the roommate that the client has the right to engage in sexual activity. D. Encourage the client who is masturbating to discontinue the behavior.

Answer: B Masturbating is a healthy human sexual behavior. The client should be provided with private time. Moving the roommate to another room could be ineffective because this may happen with the client's future roommate. The client has the right to meet physical needs, but other clients also have rights that should be respected.

Which technique would the nurse recommend to a client who reports racing thoughts that are difficult to control in periods of stress? A. Humor B. Meditation C. Guided imagery D. Progressive muscle relaxation

Answer: B Meditation is a practice that helps quiet the mind and could be especially helpful for this client. It helps reduce the internal dialogue that can cause stress. Humor, although a good technique, does not specifically address racing thoughts. Guided imagery and muscle relaxation are helpful for producing relaxation in the body but may not address racing thoughts as well as meditation does.

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease? A. Physical contact will increase dependency needs. B. Routines provide stability for clients with neurocognitive disorders. C. Regressive behavior should be interrupted immediately. D. Procedures do not have to be explained to clients with neurocognitive disorders.

Answer: B Routines provide stability for clients with neurocognitive disorders. Rituals and routines in activities of daily living provide a framework and structure for clients with Alzheimer disease, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency, and touch may have to be used judiciously depending upon the stage of Alzheimer disease. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood by clients with Alzheimer disease.

Which of these questions is included on the CAGE screening test for alcoholism? A. "Do you feel that you are a normal drinker?" B. "Have you ever felt bad or guilty about your drinking?" C. "Are you always able to stop drinking when you want to?" D. "How often did you have a drink containing alcohol in the past year?"

Answer: B The CAGE screening test for alcoholism contains four questions corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an " Eye-opener") to steady your nerves or get rid of a hangover? "Do you feel that you are a normal drinker?" and "Are you always able to stop drinking when you want to?" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST). "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT).

An individual is found unconscious and is admitted to the hospital with heroin overdose. Which nursing action is the priority? A. Monitoring level of consciousness B. Establishing a patent airway C. Monitoring for heroin withdrawal D. Establishing a therapeutic relationship

Answer: B The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Monitoring level of consciousness would be the next priority. Symptoms of heroin withdrawal will occur 6 to 8 hours after the last dose if the client has a physical addiction. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

Based on Erikson's psychosocial stages of development, which task must a 30-year-old client work through? A. Integrity versus despair B. Intimacy versus isolation C. Industry versus inferiority D. Identity versus role confusion

Answer: B The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation (intimacy versus isolation). During the integrity-versus-despair stage, the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.

Which intervention would the nurse use for a client with schizophrenia who is experiencing hallucinations? A. Advocate for client's admission to institutional care. B. Acknowledge that the client's experience is real for him. C. Prepare the client for electroconvulsive therapy. D. Advise the family to act normally around the client.

Answer: B The nurse accepts the client and the client's fears to facilitate effective communication. Today mental health therapy is directed toward returning the client to the community as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for clients with schizophrenia. Family's behavior and interaction with the client should be assessed first. Based on that assessment, the nurse may decide to teach the family how to respond when the client is actively hallucinating.

Which action would the nurse take for a client with borderline personality disorder? A. Provide an unstructured environment to promote self-expression. B. Be firm, consistent, and understanding while focusing on specific target behaviors. C. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. D. Record but ignore marked shifts in mood, suicidal threats, and temper displays because these are attention-seeking behaviors.

Answer: B The nurse would be firm, consistent, and understanding while focusing on specific target behaviors. Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

Which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"? A. Nihilistic B. Persecution C. Control D. Grandeur

Answer: B The nurse would chart about delusions of persecution. Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

Which activity would the nurse include in the plan of care for a client with vascular neurocognitive disorder? A. Reeducation program B. Supportive care interventions C. Introduction of new leisure-time activities D. Involvement in group therapy sessions

Answer: B The nurse would include supportive care interventions in the plan of care. Damaged brain cells do not regenerate. Care is directed toward preventing further damage and providing protection and support for vascular neurocognitive disorders. The deterioration of the brain cells makes plans for a reeducation program unrealistic. A client with this disorder may not be able to grasp, understand, or enjoy new leisure activities. It is beyond the scope of the client's ability to function in a group therapy session.

Which action would the nurse take when caring for a client who is experiencing a paranoid delusion? A. Touch the client's arm gently to convey concern. B. Maintain eye contact when talking with the client. C. Attempt to disprove the client's delusional thoughts. D. Speak softly when talking with others near the client.

Answer: B The nurse would maintain eye contact when talking with the client. Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse would respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

In comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? A. Memory impairment B. Abrupt onset of symptoms C. Difficulty making decisions D. Inability to use words to communicate

Answer: B The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Memory impairment and difficulty making decisions may or may not be a symptom of vascular dementia; it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment and difficulty with decision-making, but not abruptly. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.

Answer: B Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting from one topic to another with no apparent meaning is the definition of flight of ideas. In associative looseness, the connections between statements are so loose that only the speaker understands them.

A client says, "Sky, flower, angry, green, opposite, blanket." Which term describes this type of communication? A. Echolalia B. Word salad C. Confabulation D. Flight of ideas

Answer: B Word salad is an incoherent mixture of words. Echolalia is a pathological repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic.

Which functions are registered nurses (RNs) legally permitted to perform in a mental health hospital? Select all that apply. One, some, or all responses may be correct. A. Psychotherapy B. Health promotion C. Case management D. Prescribing medication E. Treating human responses

Answer: B, C, & E Health promotion, case management, and treating human responses are all within the legal scope of RN practice. RNs may use counseling interventions but may not perform psychotherapy; the members of the nursing team permitted to perform psychotherapy are psychiatric/mental health clinical nurse specialists and psychiatric/mental health nurse practitioners. Only those who are legally licensed to prescribe medications, such as psychiatric nurse practitioners, may do so.

Which signs and symptoms would the nurse observe in a client experiencing alcohol withdrawal? Select all that apply. One, some, or all responses may be correct. A. Fatigue B. Anxiety C. Runny nose D. Diaphoresis E. Psychomotor agitation

Answer: B, D, & E Anxiety, diaphoresis, and psychomotor agitation all occur with alcohol withdrawl. Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity (psychomotor agitation). Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

Which intervention would the nurse use to prevent injury to others when caring for a client with intermittent explosive disorder? Select all that apply. One, some, or all responses may be correct. A. Administer antipsychotics. B. Set limits and expectations. C. Use seclusion and time out. D. Provide structure and boundaries. E. Ignore attention-seeking behaviors.

Answer: B, D, & E When caring for clients with intermittent explosive disorder, interventions to promote safety and prevent injury to others include setting limits and expectations, providing structure and boundaries, and ignoring attention-seeking behavior. Antipsychotics and seclusion are used only as last-resort measures.

Which clinical manifestations would the nurse observe in an older client with major depressive disorder? Select all that apply. One, some, or all responses may be correct. A. Loss of memory B. Decreased appetite C. Neglect of personal hygiene D. "I don't know" answers to questions E. "I can't remember" answers to questions

Answer: BCDE The nurse would observe decreased appetite, neglect of personal hygiene, "I don't know" answers, and "I can't remember" answers. Clients with depression usually have decreased appetite. Neglect of personal hygiene is associated with depression because of low self-esteem. People who are depressed do not have physical or emotional energy; "I don't know" and "I can't remember" answers require little thought or decision-making. Depression does not cause loss of memory.

Which approach is best to use with a client who is angry and agitated? A. Confront the client about the behavior. B. Turn on the television to distract the client. C. Maintain a calm, consistent approach with the client. D. Explain to the client why the behavior is unacceptable.

Answer: C Consistency allows the client to predict the nurse's behavior and a calming approach helps decrease agitation. Confronting the client may escalate anger and agitation. Environmental stimulants should be decreased, not increased. An agitated client cannot attend to logical explanations and perceived criticisms should be avoided.

A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing? A. Complex bereavement B. Anticipatory C. Disenfranchised D. Complicated

Answer: C Disenfranchised grief is grief over a loss that is not a socially recognized relationship. Grief after an abortion or death of a pet are examples of disenfranchised grief. Complex bereavement is a prolonged (longer than 12 months) and dysfunctional grieving. In anticipatory grief, the loss is expected or predictable so there is an opportunity to work through a part of the grief process before death. Complicated grieving occurs when there is a failure to progress through the grief process. There is preoccupation about the deceased, accompanied by depression, anger, and feelings of emptiness.

Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech? A. Touch B. Silence C. Focusing D. Summarizing

Answer: C Focusing is used when a client rambles or jumps from topic to topic; the intended meaning is easier to understand if the client focuses on one specific aspect. Touch invades the client's space and could increase anxiety, which increases pressured speech. Use of silence allows the client to continue rambling. Until the concern is identified and explored, summarizing is impossible.

The nurse advises a client with anxiety to focus on a positive scene. Which relaxation technique is the nurse using? A. Meditation B. Biofeedback C. Guided imagery D. Progressive muscle relaxation

Answer: C Guided imagery is the process of using pleasant images to help reduce stress and anxiety levels. Biofeedback uses precise measurements of specific indicators to help users learn to control them. Meditation is a discipline that trains the mind to produce calm and insight into one's life. It involves concentrating on a specific object or sound, such as breathing or a flickering candle, to quiet the mind. Progressive muscle relaxation is the deliberate tensing and relaxing of specific muscles to elicit the relaxation response.

Which nursing intervention is the most therapeutic to help a late-middle-age individual cope with the emotional aspects of aging? A. Focusing on the individual's past experiences B. Scheduling the individual to attend lectures on aging C. Assisting the individual with plans for the future D. Encouraging the individual to focus on her or his career

Answer: C Helping an individual maintain an interest in the future is therapeutic. It is forward looking and fosters a positive attitude. Focusing on the individual's past experiences is appropriate for an older adult, not a late-middle-age adult. Lectures may or may not include emotional aspects of aging; also, the client should express an interest in attending lectures. Encouraging the individual to focus on her or his career does not address concerns about the future.

Which factor would precipitate a client's use of confabulation? A. Ideas of grandeur B. Need for attention C. Marked memory loss D. Difficulty in accepting the diagnosis

Answer: C Marked memory loss precipitates a client's use of confabulation. A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not precipitate use of confabulation. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. The individual uses confabulation as an attempt to mask memory loss, not because of difficulty in accepting the diagnosis.

Which disorder is defined as a preoccupation with the fear of having a serious disease? A. Conversion disorder B. Somatization disorder C. Hypochondriac disorder D. Body dysmorphic disorder

Answer: C Preoccupation with fears of getting or having a serious disease is called hypochondriasis. The condition usually exists for 6 months or longer, persists despite negative medical tests and reassurance, and results in social or occupational impairment. Conversion disorder is characterized by the presence of 1 or more symptoms related to a neurological problem that has no organic cause. Somatization disorder is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least 1 symptom that suggests a neurological disorder. Body dysmorphic disorder is characterized by preoccupation with some imagined defect in appearance that causes marked distress and significant impairment in social and occupational function.

The nurse says, "Let's see whether we both mean the same thing." Which communication technique is the nurse using? A. Reflecting feelings B. Making observations C. Seeking consensual validation D. Placing events in sequence

Answer: C Seeking consensual validation is a technique that prevents misunderstanding so the client and the nurse can work toward a common goal in the therapeutic relationship. Reflecting feelings and making observations are therapeutic techniques, but the nurse must make a best-guess interpretation about the client's feelings and actions. Placing events in sequence helps the nurse and client organize information. Reflection, observations, and sequencing still require consensual validation.

When discussing standards for involuntary admission to a mental health facility, which factor is related to safety? A. Mental illness B. Severe disability C. Currently cutting D. Needs treatment

Answer: C The client who is a danger to others or to himself or herself is a safety factor that would necessitate involuntary admission to a mental health facility. This would include the client who is cutting. Having a mental illness, a severe disability, and an inability to know that treatment is required are reasons for involuntary admission but are not safety factors.

Which defense mechanism is a client displaying when the client can no longer remember why an event was stressful, even though it happened just 3 days ago? A. Denial B. Regression C. Repression D. Dissociation

Answer: C The client's inability to recall is an example of repression, which is the unconscious and involuntary forgetting of painful events, ideas, and conflicts. Denial is an unconscious refusal to admit an unacceptable situation. Regression is a return to an earlier, more comfortable developmental level. Dissociation is the separation and detachment of emotional affect and significance from an idea, situation, or incident.

The nurse is working with a client who is crying and very upset. The client states, "I don't want to talk about it; it is too painful." Which question would the nurse ask to obtain the most information about the client's safety? A. "Is there anyone I can notify of your condition?" B. "Have you ever thought about going to a safe house?" C. "Do you feel that your life is in danger where you live?" D. "Do you belong to any churches in the area that could help?"

Answer: C The nurse would ask about safe living conditions to determine if the client feels his or her life is in danger in the home. The questions regarding asking about notifying someone of the client's condition and about church membership will assess situational support systems. Asking about going to a safe house would be appropriate if the client is found to be in actual danger.

Which approach would the nurse take for a client with hallucinations who suddenly rises and shouts, "Stop saying that. Who do you think you are"? A. Explaining to the client that ignoring the voices will make them disappear B. Taking the client to the client's room for a quiet place to think away from other clients C. Telling the client that the voices are not heard by the nurse, then offering to listen to music together D. Pointing out to the client the inappropriateness of the behavior in a nonthreatening, nonjudgmental manner

Answer: C The nurse would tell the client that the nurse does not hear the voices and then offer to listen to music together. Telling the client that the nurse doesn't hear the voices and offering to listen to music together presents the reality of the situation and helps distract the client during a threatening hallucination. Telling the client to simply ignore the voices is not therapeutic. It will be difficult for the client to do this. Taking the client to the client's room encourages withdrawal and isolation and will not stop the hallucination. Pointing out the inappropriateness of the client's behavior will have little effect on it and will not stop the hallucination.

Which defense mechanism are the parents displaying when have a bitter argument immediately after being told that their child has acute myelogenous leukemia? A. Denial B. Projection C. Displacement D. Compensation

Answer: C The parents are focusing their feelings about their child's prognosis on someone or something else—in this case, each other. Denial is ignoring, avoiding, or refusing to recognize painful realities. Projection is the attribution of one's own feelings to another person. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

Which behavior is most commonly used by an individual with a phobic disorder? A. Rumination B. Desensitization C. Avoidance D. Confrontation

Answer: C The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Rumination (continuously rethinking about an issue) is more common in depression. Desensitization is a therapy that is used to treat phobias by systematically exposing the individual to the phobic object using a series of small steps. People with phobias fear confrontation with the phobic object and are less likely to attempt this without the help of a therapist.

Which primary symptom would the nurse assess for in a boy who has encopresis? A. Practicing self-mutilation B. Practicing self-induced vomiting C. Passing feces either voluntarily or involuntarily into inappropriate places D. Passing urine either voluntarily or involuntarily into inappropriate places

Answer: C The primary symptom the nurse would observe in encopresis is passing feces either voluntarily or involuntarily into inappropriate places. Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-mutilation; self-mutilation occurs in borderline personality disorder. Encopresis does not involve self-induced vomiting; self-induced vomiting occurs with eating disorders. The passage of urine into inappropriate places is called enuresis.

A woman with five children and multiple facial injuries says, "My husband is an alcoholic, and he just beat me up." Which intervention would the nurse use? A. Report her statements and injuries to the police. B. Refer her to a community legal aid program. C. Inquire about her and the children's safety. D. Discuss taking the children and leaving the husband.

Answer: C The safety of the victim and the children must be assessed, because research shows that children of an alcoholic parent are commonly abused. If the nurse suspects child abuse, a report must be made to child protective services. State laws determine whether the police must be contacted. Referring to legal aid and discussions of leaving are premature; these actions can precipitate abuse if the husband finds out.

Which portion of the nervous system is primarily responsible for the clinical manifestations that occur during a crisis? A. Central nervous system B. Peripheral nervous system C. Sympathetic nervous system D. Parasympathetic nervous system

Answer: C The sympathetic nervous system reacts to stress by releasing epinephrine, which prepares the body to fight or flee by increasing the heart rate, constricting peripheral vessels, and increasing oxygen supply to muscles. Although the central nervous system (brain) responds to stress, it is the sympathetic nervous system that is primarily affected. The peripheral nervous system includes the sympathetic and parasympathetic nervous systems; however, the sympathetic nervous system is primarily affected, and the parasympathetic nervous system does not play a role in the fight-or-flight reaction. The parasympathetic nervous system has the opposite effects of the sympathetic nervous system.

An older client who has been taking lorazepam for several years is scheduled for a procedure that requires the client to be awake for the duration. The client has a history of violence and hypotension. Which antipsychotic medication is appropriate to administer to the client during the procedure? Select all that apply. One, some, or all responses may be correct. A. Loxapine B. Risperidone C. Haloperidol D. Perphenazine E. Olanzapine IM F. Chlorpromazine

Answer: C, D Haloperidol and perphenazine are the most appropriate medications. Loxapine is available only through a restricted program and would not be suitable for this client. Risperidone can cause hypotension with reflex tachycardia and carries a risk of stroke among older adult clients. Olanzapine IM should be avoided with lorazepam and also raises the risk of stroke in older adults. Chlorpromazine is very sedating.

The nurse manager is educating a group of nurses regarding older adults and the risk for suicide. Which factors would be included in this presentation? Select all that apply. One, some, or all responses may be correct. A. Spiritual beliefs B. Presence of family C. Loss of independence D. Chronic health conditions E. Access to many medications

Answer: C, D, & E Older adults, especially men over the age of 65, are at increased risk for committing suicide. Risk factors include loss of independence, presence of chronic health conditions, and access to large amounts of medications. Positive factors that decrease the risk for self-harm include spiritual beliefs and presence of family in the life of the older adult.

Which intervention would provide comfort to the client experiencing alcohol toxicity? A. Dim the lights. B. Use distraction. C. Offer activities. D. Stay with the client.

Answer: D Agitation and anxiety are common in clients experiencing alcohol toxicity. Staying with the client as much as possible will help decrease their anxiety and provide the opportunity to reorient them as needed. Dimming the lights may place the client at risk for injury due to their impaired judgment and lack of coordination. Distraction and activities are not appropriate nursing interventions at this time.

A young college student smiles and angrily says, "If my girlfriend's pregnancy test is positive, I'll drop out of school, marry her, and get a full-time job." Which term would the nurse use to document the client's verbal and nonverbal behaviors? A. Double-bind message B. Mixed message C. False reassurance D. Incongruent message

Answer: D Although the client's facial expression suggests happiness, the client's tone of voice gives the message of anger; the behaviors are incongruent. A double-bind message occurs when a person in power uses 2 or more contradictory statements or behaviors; the receiver is trapped in a no-win situation. The student is giving a mixed message, but for documentation purposes, incongruent is the preferred term and in this case is more precise. False reassurance occurs when a speaker tells a distressed person that everything will be okay, when the outcomes are not guaranteed.

An older client is able to perform activities of daily living, but he has vague physical complaints and has experienced multiple deaths of friends and family and has lost his social roles. Which question is the most therapeutic? A. "Can you cope with being alone?" B. "Have you considered assisted living?" C. "What is the main problem today?" D. "How do you feel about your life now?"

Answer: D An open-ended question is the most therapeutic invitation to encourage the client to discuss hopes and frustrations without being threatening or probing. Closed questions (Can you cope? Have you considered?) provide little information and are not the best choice for clients who need encouragement to verbalize feelings and needs. Focusing on one main problem suggests that the client must limit his communication.

Before discharging an anxious client, which information about anxiety would the nurse teach the family? A. Anxiety is a totally unique feeling and experience. B. Apprehension is generalized to the total environment. C. Fears results from conscious actions, thoughts, and wishes. D. Anxiety is a pattern of emotional and behavioral responses to stress.

Answer: D Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.

According to Erikson's psychosocial stages of development, in which stage would toilet training be achieved? A. Trust versus mistrust B. Initiative versus guilt C. Industry versus inferiority D. Autonomy versus shame

Answer: D Children between the ages of 18 months and 3 years attempt to develop independence; control over the self; and mastery of toileting, dressing, and feeding. Infants between birth and 1 year attempt to meet basic oral and sensory needs and develop a sense of trust in themselves and others. Children between the ages of 3 and 6 years develop a sense of purpose; they accept responsibility, learn to be cooperative, and are enthusiastic about helping others. Children between the ages of 7 and 11 years develop a sense of competence; through learning and mastery of skills, they develop self-assurance.

An older adult seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? A. Lying B. Denying C. Fantasizing D. Confabulating

Answer: D Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire.

Which term describes the disturbance in mood and affect seen in clients who are depressed? A. Euphoric B. Labile C. Expansive D. Dysphoric

Answer: D Dysphoric describes feelings of hopelessness and sadness, which are symptomatic of depression. Euphoric is a feeling of elation and joyfulness; this is often seen in the early manic phase of bipolar disorder. A labile mood describes a rapid change in mood, for example, clients with dementia may be easily upset and then happy. An expansive (talkative, exaggerated friendliness) mood is usually associated with the manic phase of bipolar disorder.

Which action would the nurse therapist take when the father of an autistic child states that the family members wish to share their religious beliefs with the therapist? A. Ask the father if religious beliefs relate to the child's autism. B. Include the mutual discussion of religious beliefs. C. Invite the family's religious leader to a therapy session. D. Encourage discussion of their religion in the sessions.

Answer: D If religious beliefs are a family concern, the nurse should encourage discussion of their thoughts and feelings; this would include the relationship of religious beliefs to the child's autism if this topic is important to the family. The role of the nurse is to facilitate and listen, not to participate in a mutual discussion about religious beliefs. The religious leader is not part of the family unit and should be invited only if this is requested by the family.

Which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders? A. Emotional cause B. Feeling of illness C. Restriction of activities D. Underlying pathophysiology

Answer: D Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic symptom disorders usually do not. The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatic symptom disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

The nurse hears a child who was not invited to a sleepover say, "I have better things to do than go to that sleepover." Which defense mechanism would the nurse conclude the child is using? A. Denial B. Projection C. Regression D. Rationalization

Answer: D Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation; the child is not avoiding the reality of the sleepover. Projection is blaming others for one's shortcomings; the child is not blaming others for not being invited to the sleepover. Regression is returning to an earlier more familiar mode of behavior; the child is not regressing.

Which defense mechanism would be exhibited when a client with alcohol use disorder states, "I function better when I'm drinking than when I'm sober"? A. Sublimation B. Suppression C. Compensation D. Rationalization

Answer: D The client is using rationalization. The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

Which intervention is the most important for a young female client who was raped 3 days ago and continually talks about the trauma of being sexually assaulted? A. Getting her involved with a rape therapy group B. Remaining available and supportive to limit destructive anger C. Exploring her feelings about men to promote future relationships D. Providing a safe environment that permits the ventilation of feelings

Answer: D The client needs to be able to express her current feelings in a safe environment. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.

Which action would the school nurse take for a child who tells the nurse, "My father has been getting into bed with me at night and touching me"? A. Ask the child to describe the touching. B. Talk to the teacher about any inappropriate behavior. C. Contact the father to come to the school immediately. D. Report the child's conversation to child protective services.

Answer: D The nurse is legally responsible for reporting suspected child abuse to the appropriate child protection agency. The agency must assess the situation and intervene if necessary to protect the child. Asking the child to describe the touching may worsen the psychological trauma; the nurse would listen and demonstrate concern. The nurse does not need any more data from the teacher to have a reasonable suspicion of child abuse; the situation must be reported. Contacting the father may result in more abuse or in the child not reporting future abuse.

A newly admitted client quietly listens to the nurse's explanation of the mental health unit and then says, "So this is where they keep the crazies." Which response would the nurse use? A. "These people are emotionally ill; we never use words like crazy or nuts." B. "Some people feel that way. Let's talk about mental health." C. "Would you like me to explain the philosophy of psychiatric care?" D. "Do you feel that a person has to be crazy to need mental health services?"

Answer: D The nurse reflects the specific fear of being "crazy" and invites discussion about the client's misconceptions of mental health services. The focus should remain on the client, not on others (these people or some people). Explaining the philosophy of care is an example of intellectualization, which is defense mechanism that incorporates facts and avoids emotional content.

The client says, "I don't see how talking to you can possibly help." Which response would the nurse use? A. "I can see how you might feel that way now, but I hope you'll change your mind." B. "You'll never know whether or not it's helpful unless you're willing to give it a try." C. "The one-on-one relationship has proved helpful for others, and you should give it a try." D. "I hope I can help you express and better understand your thoughts and feelings."

Answer: D The nurse uses an optimistic response (I hope) that clarifies the purpose of the relationship (to express and understand). By making an inaccurate reflection (I can see how you might feel), the nurse comes across as being unsure if talking will help. Platitudes (you'll never know, unless you give it a try) are not helpful. Placing the focus on others (proved helpful for others) diminishes the client.

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? A. Infuse intravenous fluids. B. Monitor the level of anxiety. C. Obtain frequent vital signs. D. Administer chlordiazepoxide

Answer: D The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic hyperactivity but does not directly affect client safety.

Which response would the nurse make to the husband who told his suicidal wife that he would bring their 26-month-old daughter to visit and asks if that would be possible. Which is the best response by the nurse? A. "Probably so, but you'd better check with her primary health care provider first." B. "Of course! Children of all ages are welcome to visit relatives." C. "It could be very upsetting for your child to see her mother so depressed." D. "Tell me what your wife said when you offered to bring your child for a visit."

Answer: D The nurse would determine whether the spouse has discussed the child visiting with the client before commenting further. The responses, "Probably so, but you'd better check with her primary health care provider first," and "Of course! Children of all ages are welcome to visit relatives," assume that the client has consented to the visit; this assumption may be incorrect. The response, "It may be very upsetting for your child to see her mother so depressed," makes an assumption that requires more data and discussion to validate.

Which intervention would the nurse include when developing a plan of care for an older client with dementia? A. Explain to the client the details of the regimen. B. Demonstrate interest in the client's various likes and dislikes. C. Be firm when dealing with the client's attitudes and behaviors. D. Provide consistency in carrying out nursing activities for the client.

Answer: D The nurse would include providing consistency in carrying out nursing activities for the client. Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed for clients with dementia. Although demonstrating interest in the client's likes and dislikes helps individualize care, in a client with dementia likes and dislikes may be hard to remember. Being firm when dealing with the client's attitudes and behaviors may increase anxiety in the client with dementia; some degree of flexibility by the nurse helps decrease outburst from clients with dementia.

Which conclusion would the school nurse make about a female teenager who has anorexia nervosa and states that she thinks she is pregnant even though she has had intercourse only once, more than a year ago? A. Is using magical thinking B. Is submitting to peer pressure C. Is lying about the last time she had intercourse D. Is lacking knowledge that the disease can cause amenorrhea

Answer: D The nurse would make the conclusion that the client is lacking knowledge that the disease can cause amenorrhea. The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse might question the timeline again, the client's nutritional status would be explored first.

Which strategy would the nurses use to minimize aggressive behaviors from the client with a neurocognitive disorder? A. Limit the time staff and the client spend together. B. Follow an outline of consequences for uncooperative behavior. C. Use the client's preferences as a reward or a punishment. D. Identify nursing staff members whom the client prefers.

Answer: D The strategy is to identify nursing staff members whom the client prefers. The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with neurocognitive disorder cannot be held responsible for uncooperative behavior. Clients with neurocognitive disorder will not remember and learn from a reward system.

Which behavior would indicate that a client with a long history of alcohol use disorder is ready for treatment? A. Drinking only socially B. Avoiding drinking for a week C. Being hospitalized for detoxification D. Verbalizing an honest desire for help

Answer: D Verbalizing an honest desire for help indicates readiness for treatment. When clients with alcohol problems voice a desire for help, it usually signifies that they are ready for treatment, because they are admitting they have a problem. Drinking only socially does not indicate a readiness for treatment because adherence to an alcohol treatment program requires abstinence. A week is too short a time to signal readiness for treatment. Hospitalization alone is not an indication that the client is really ready for treatment; many factors can influence admission.

Which response is best to give a client who has schizophrenia, when he interjects random and nonsensical sentences that have nothing to do with the main conversational topics? A. "You aren't making any sense; let's talk about something else." B. "Why don't you take a rest? We can talk again later this afternoon." C. "I'd like to understand what you're saying, but you're too confused now." D. "I'd like to understand what you're saying, but I'm having trouble following you."

Answer: D When the nurse conveys a desire to understand, this increases the client's feeling of self-esteem. Nurse also states reality and the reality is that as a listener, the conversation is hard to follow, and the intended meaning is not being received. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The other responses serve to block or stop communication, and they suggest that the nurse doesn't want to speak to the client unless he makes sense.

Which behavior is the nurse displaying while caring for a depressed 75-year-old woman who reminds her of her grandmother when she spends extra time and attention and brings home-baked cookies? A. Affiliation B. Displacement C. Compensation D. Countertransference

Answer: D With countertransference, the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or conflicted. Displacement is the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation is attempting to balance deficiencies in one area by excelling in another area.

Which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is the president? Select all that apply. One, some, or all responses may be correct. A. Schizoid B. Paranoid C. Histrionic D. Borderline E. Narcissistic F. Schizotypal

Answer: F People with schizotypal personality disorder demonstrate symptoms that are strikingly strange and unusual, such as magical thinking, odd beliefs, strange speech patterns, and inappropriate affect. A client telling an odd and rambling story about their dog being the president would be demonstrating behavior consistent with schizotypal personality disorder. People with schizoid personality disorder display a lack of interest in social relationships. Paranoid personality disorder is characterized by a longstanding distrust and suspicion of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. People with histrionic personality disorder are excitable and dramatic yet often high functioning. Borderline personality disorder is characterized by severe impairments in functioning caused by patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated belief in one's own importance, and a lack of empathy.