Exam 3 psy

Pica

- Eating non-food items well past toddler age - Not part of other illnesses - Pregnancy

Rumination

- Regurgitation with re-chewing, re-swallowing or spitting - No medical or mental reason

Avoidant/restrictive food intake

- Starts in childhood - 40% of "picky" eaters resolve on their own - Low BMI but no distorted body image

1. a; 2. b; 3. d; 4. c; 5. d;

1. Nick, a construction worker, is on duty when a nearly completed wall suddenly falls, crushing a number of his co-workers. Although badly shaken initially, he seemed to be coping well. About 2 weeks after the tragedy, he begins to experience tremors, nightmares, and periods during which he feels numb or detached from his environment. He finds himself frequently thinking about the tragedy and feeling guilty that he was spared while many others died. Which statement about this situation is most accurate? a. Nick has acute stress disorder and will benefit from antianxiety medications. b. Nick is experiencing posttraumatic stress disorder (PTSD) and should be referred for outpatient treatment. c. Nick is experiencing anxiety and grief and should be monitored for PTSD symptoms. d. Nick is experiencing mild anxiety and a normal grief reaction; no intervention is needed. 2. You are caring for Susannah, a 29-year-old who has been diagnosed with dissociative identity disorder. She was recently hospitalized after coming to the emergency department with deep cuts on her arms with no memory of how this occurred. The priority nursing intervention for Susannah is: a. Assist in recovering memories of abuse. b. Maintain 1:1 observation. c. Teach coping skills and stress-management strategies. d. Refer for integrative therapy. 3. You are caring for Connor, an 8-year-old boy who has been diagnosed with reactive attachment disorder. Which of the following nursing outcomes would be the most appropriate to achieve? a. Increases ability to self-control and decreases impulsive behaviors. b. Avoids situations that trigger conflicts. c. Expresses complex thoughts. d. Writes or draws feelings in a journal. 4. Ashley is a 21-year-old college student who was sexually assaulted at a party. She was seen in the local emergency department and referred for counseling after being diagnosed by the provider on call as having acute stress disorder. Which of the following treatment modalities would you expect to see used in therapy with Ashley? a. Aversion therapy b. Stress-reduction therapy c. Cognitive behavioral therapy d. Short-term classical analysis therapy 5. Jamie, age 24, has been diagnosed with a dissociative disorder following a traumatic event. Jamie's mother asks you, "Does this mean my daughter is now crazy?" Your best response would be: a. "People with dissociative disorders are out of touch with reality, so in that way, your daughter is now mentally ill. Don't worry. Treatment is available." b. "Jamie will most likely need long-term intensive inpatient treatment to deal with her traumatic memories as well as to work through her delusions." c. "Most mental health providers are skeptical about dissociative disorders and aren't sure they truly exist. Jamie may be making up her symptoms as a cry for help." d. "Jamie is dealing with the anxiety associated with the trauma by separating herself from it. With treatment, she can get back to her previous level of functioning."

1. d; 2. c; 3. a, c, d, e; 4. a; 5. d;

1. As a nurse on an adolescent psychiatric-mental health nursing unit, you will often encounter teenagers who are misinformed about their growth and development as well as sexuality. What information would you include in a series of teaching sessions that would help these adolescents acquire a better understanding of the developmental changes they are going through? 2. To understand your own beliefs, answer these questions: a. Are you comfortable with your own sexuality? With that of others? b. Are you judgmental? c. Could you be helpful to someone who has a sexual disorder? d. What factors have influenced your beliefs and values regarding sexuality? e. What do you think is the impact of sexually explicit online content, television, music videos, and movies on your sexual attitudes, values, and beliefs? 3. During a one-to-one session, Mrs. Chase, a patient who was admitted to your inpatient unit with major depressive disorder and generalized anxiety disorder, confides her concern about her 17-year-old son, Alex. She becomes tearful and says, "I don't know what I've done wrong. Alex was arrested for exposing himself to a girl at school. I'm worried that he may begin doing even worse things." a. Provide Mrs. Chase with information regarding Alex's condition and his probable prognosis. b. What sort of feelings about Alex within yourself would you have to be aware of in order to give Mrs. Chase the best possible care? Chapter Review 1. Which patient statement suggests a concern over one's ability to perform sexually? a. "My partner and I aren't as close as we once were." b. "I'm not as desirable as I once was." c. "My personal life has changed a lot." d. "I'm not the partner I used to be." 2. The nurse should plan to educate male patients who are taking selective serotonin reuptake inhibitors (SSRIs) on the possible development of which common side effect? a. Impotence b. Gynecomastia c. Decreased libido d. Premature ejaculation 3. Which medications are currently approved for the treatment of male erectile disorder? Select all that apply. a. Sildenafil (Viagra) b. Flibanserin (Addyi) c. Tadalafil (Cialis) d. Vardenafil (Levitra) e. Avanafil (Stendra) 4. Which statement describes a common sexual side effect of diazepam (Valium)? a. "I'm just not interested in sex as much." b. "I'm experiencing vaginal dryness." c. "I am having prolonged erections." d. "My breasts have gotten larger." 5. Obtaining a sexual history can be embarrassing for the patient and practitioner. Experience with addressing the topic can help, as can which of the following? a. Using informal language familiar to the patient's age group b. Avoiding specifics and focusing the interview on general topics c. Avoiding eye contact d. Using a professional tone of voice and a relaxed posture

Intimate Partner Violence:

"physical, sexual, psychological harm by a current or former partner or spouse"

1. a; 2. d; 3. b; 4. a, b, d; 5. a, b, c;

1. Which statement demonstrates a well-structured attempt at limit setting? a. "Hitting me when you are angry is unacceptable." b. "I expect you to behave yourself during dinner." c. "Come here, right now!" d. "Good boys don't bite." 2. Which activity is most appropriate for a child with ADHD? a. Reading an adventure novel b. Monopoly c. Checkers d. Tennis 3. Cognitive-behavioral therapy is going well when a 12-year-old patient in therapy reports to the nurse practitioner: a. "I was so mad I wanted to hit my mother." b. "I thought that everyone at school hated me. That's not true. Most people like me and I have a friend named Todd." c. "I forgot that you told me to breathe when I become angry." d. "I scream as loud as I can when the train goes by the house." 4. What assessment question should the nurse ask when attempting to determine a teenager's mental health resilience? Select all that apply. a. "How did you cope when your father deployed with the Army for a year in Iraq?" b. "Who did you go to for advice while your father was away for a year in Iraq?" c. "How do you feel about talking to a mental health counselor?" d. "Where do you see yourself in 10 years?" e. "Do you like the school you go to?" 5. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply. a. Limited language skills b. Level of cognitive development c. Level of emotional development d. Parental denial that a problem exists e. Severity of the typical mental illnesses observed in young children

1. b; 2. a, b, c; 3. b; 4. a, b, d; 5. a, b, c, e;

1. Which statement made by a 9-year-old child after hitting a classmate is a typical comment associated with childhood conduct disorder? a. "I'm sorry, I won't hit him again." b. "He deserved it for being a sissy." c. "I didn't think I hit him very hard." d. "He hit me first. You just didn't see it." 2. What assessment data would support a diagnosis of conduct disorder? Select all that apply. a. Evidence of social isolation b. Arrested twice for disorderly conduct c. Expresses difficulty in keeping employment d. Demonstrates objective signs of phobia e. Exhibits signs of chronic self-mutilation 3. Which event experienced in the patient's childhood increases the risk of the development of behaviors associated with intermittent explosive disorder? a. Orphaned at age 4 b. Physically abused from ages 3 to 10 c. Born with a chronic congenital disorder d. Has one parent who has been diagnosed with obsessive-compulsive disorder 4. What is a common behavior observed in a patient diagnosed with intermittent explosive disorder? Select all that apply. a. Short attention span. b. Threatens suicide. c. Often purges after eating. d. Uses alcohol to excess. e. States, "Everyone is out to get me." 5. When the nurse is discussing oppositional defiant disorder with a group of parents, what information about the disorder should be included? Select all that apply a. Classic symptoms, including anger, irritation, and defiant behavior. b. The fact that children generally outgrow the behaviors without formal treatment. c. That severity is considered mild when symptoms are present in only one setting. d. That the disorder is diagnosed equally in both males and females. e. That the terms argumentative and defiant are often used to describe the patient.

1. b; 2. d; 3. d, e; 4. d; 5. d;

17 1. The care plan of a patient diagnosed with a somatic disorder includes the nursing diagnosis impaired coping. Which patient behavior demonstrates a successful outcome for that nursing diagnosis? a. Showers and dresses in clean clothes daily b. Calls a friend to talk when feeling lonely c. Spends more time talking about pain in her abdomen d. Maintains focus and concentration 2. Which patient is at greatest risk for developing a stress-induced myocardial infarction? a. A patient who lost a child in an accidental shooting 24 hours ago b. A woman who has begun experiencing early signs of menopause c. A patient who has spent years trying to sustain a successful business d. A patient who was diagnosed with chronic major depressive disorder 10 years ago 3. What precipitating emotional factor has been associated with an increased incidence of cancers? Select all that apply. a. Anxiety b. Job-related stress c. Acute grief d. Feelings of hopelessness and despair from depression e. Prolonged, intense stress 4. You are caring for Aaron, a 38-year-old patient diagnosed with somatic symptom disorder. When interacting with you, Aaron continues to focus on his severe headaches. In planning care for Aaron, which of the following interventions would be appropriate? a. Call for a family meeting with Aaron in attendance to confront Aaron regarding his diagnosis. b. Educate Aaron on alternative therapies to deal with pain. c. Improve reality testing by telling Aaron that you do not believe that the headaches are real. d. After a limited discussion of physical concerns, shift focus to feelings and effective coping skills. 5. Living comfortable and materialistic lives in Western societies seems to have altered the original hierarchy proposed by Maslow in that: a. Once lower-level needs are satisfied, no further growth feels necessary. b. Self-actualization is easier to achieve with financial stability. c. Esteem is more highly valued than safety. d. Focusing on materialism reduces interests in love, belonging, and family.

6. a; 7. c; 8. c; 9. d; 10. a

6. A young child is found wandering alone at a mall. A male store employee approaches and asks where her parents are. She responds, "I don't know. Maybe you will take me home with you?" This sort of response in children may be due to: a. A lack of bonding as an infant b. A healthy confidence in the child c. Adequate parental bonding d. Normal parenting 7. During a routine health screening, a grieving widow whose husband died 15 months ago reports emptiness, a loss of self, difficulty thinking of the future, and anger at her dead husband. The nurse suggests bereavement counseling. The widow is most likely suffering from: a. Major depression b. Normal grieving c. Adjustment disorder d. Posttraumatic stress disorder 8. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. The foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states: a. "I understand that imaginary friends are abnormal." b. "I understand that imaginary friends are a maladaptive behavior." c. "I understand that imaginary friends are a coping mechanism." d. "I understand that we should tell the child that imaginary friends are unacceptable." 9. The school nurse has been alerted to the fact that an 8-year-old boy routinely play acts as a police officer, "locking up" other children on the playground to the point where the children get scared. The nurse recognizes that this behavior is most likely an indication of: a. The need to dominate others b. Inventing traumatic events c. A need to develop close relationships d. A potential symptom of traumatization 10. A pregnant woman is in a relationship with a male who routinely abuses her. Her unborn child may engage in high-risk behavior as a teen as a result of: a. Maternal stress b. Parental nurturing c. Appropriate stress responses in the brain d. Memories of the abuse

5. d; 6. c; 7. b; 8. c; 9. a; 10. d

5. Which comorbid condition would result in cautious use of an SSRI for a patient with chronic aggression? a. Asthma b. Anxiety disorder c. Glaucoma d. Bipolar disorder 6. Patrick is a widower with four daughters. He enjoyed a healthy relationship with each of them until they reached puberty. As the girls began to mature physically, he acted in an aggressive manner, often beating them without provocation. Patrick is most likely acting on: a. Self-protective measures b. Stress of raising four daughters c. Frustration of unhealthy desire d. Motivating his daughters to be chaste 7. A nurse named Darryl has been hired to work in a psychiatric intensive care unit. He has undergone training on recognizing escalating anger. Which statement indicates that he understands danger signs in regard to aggression? a. "I need to be aware of patients who are withdrawn and sitting alone." b. "An obvious change in behavior is a risk factor for aggression." c. "Patients who seek constant attention are more likely to be violent." d. "Patients who talk to themselves are the most dangerous." 8. An effective method of preventing escalation in an environment with violent offenders is to develop a level of trust through: a. A casual authoritative demeanor b. Keeping patients busy c. Brief, frequent, nonthreatening encounters d. Threats of seclusion or punishment 9. A 24-hour observation is a good choice for restraint in which of the following patients? a. An inmate with suicidal ideation on hospice care b. A sex offender in the psychiatric intensive care unit c. An aggressive female with antisocial personality disorder d. An inmate diagnosed with paranoid schizophrenia 10. Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are conditions that: a. Frequently result in out of control behavior. b. Respond well to therapeutic holding. c. Necessitate the use of only two-point restraint. d. Contraindicate restraint and seclusion.

6. a-1, b-5, c-3, d-2, e-4; 7. a, b, d; 8. c; 9. b; 10. b

6. Pam, the nurse educator, is teaching a new nurse about seclusion and restraint. Order the following interventions from least (1) to most (5) restrictive: a. With the patient, identify the behaviors that are unacceptable and consequences associated with harmful behaviors b. Placing the patient in physical restraints c. Allowing the patient to take a time-out and sit in his or her room d. Offering a PRN medication by mouth e. Placing the patient in a locked seclusion room 7. In pediatric mental health, there is a lack of sufficient numbers of community-based resources and providers, and there are long waiting lists for services. This has resulted in: Select all that apply. a. Children of color and poor economic conditions being underserved b. Increased stress in the family unit c. Markedly increased funding d. Premature termination of services 8. Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his "nice" mom, that he loves school, and gets above average grades. The strongest explanation of this response is: a. Temperament b. Genetic factors c. Resilience d. Paradoxical effects of neglect 9. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that: a. Time-out is an important part of April's baseline discipline. b. Time-out is no longer an effective therapeutic measure. c. April enjoys time-out and acts out to get some alone time. d. Time-out will need to be replaced with seclusion and restraint. 10. Adolescents often display fluctuations in mood along with undeveloped emotional regulation and poor tolerance for frustration. Emotional and behavioral control usually increases over the course of adolescence due to: a. Limited executive function b. Cerebellum maturation c. Cerebral stasis and hormonal changes d. A slight reduction in brain volume

6. b; 7. a; 8. b; 9. b; 10. a, b, d, e

6. Secondary effects of abuse often manifest as arrested development in children due to the fact that: a. Coping is easier than emotional growth b. Energy for development is diverted to coping c. Children cannot differentiate love from abuse d. Abuse fosters a sense of belonging, even if dysfunctional 7. The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions 8. The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and older adults due to: a. The love they have for parents or children. b. Their limited options. c. The need to feel safe at home. d. Other relatives do not want them. 9. An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: a. A decrease in family interaction so there are fewer opportunities for abuse to occur. b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. c. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. d. A triad of treatment modalities, including medication, counseling, and role-playing opportunities. 10. Perpetrators of domestic violence tend to: Select all that apply. a. Have relatively poor social skills and have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.

6. a; 7. d; 8. a; 9. c; 10. a

6. Tommy, a 12-year-old boy admitted to the pediatric psychiatric unit, has recently been diagnosed with conduct disorder. In the activity room, the games he wanted to play were already in use. He responded by threatening to throw furniture and to hurt those who had the game he wanted. Nancy, a registered nurse, recognizes that Tommy's therapy must include which of the following? a. Consistency in implementing the consequences of breaking rules b. Empathetic reasoning when Tommy acts out in the activity room c. Teaching Tommy the benefits of socializing d. Solitary time so that Tommy can think about his actions 7. Santiago, an adolescent in a treatment facility, is loudly displaying anger with a visiting family member in the day room. It is obvious to the nurse that this pattern has played out before. Violence is often escalated when family members or authority figures a. Use a soft tone of voice to gain control of the situation b. Move away from the agitated person in fear c. Use simple words to communicate d. Engage in a power struggle 8. The impulse control spectrum can begin in childhood and continue on into adulthood, often morphing into criminal behaviors. Working with patients diagnosed with these disorders, the best examples of expressed emotion by the nursing staff are a. Low to prevent emotional reactions b. Matched to the patient's level of emotion c. Flat without evidence of any emotional output d. High in expression to improve therapeutic patient emotions 9. Claude is a new nurse on the psychiatric unit. He asks a senior nurse on staff for advice in working with patients with oppositional defiant disorder. Which statement reflects advice on solid therapeutic communication? a. "When you are correcting behavior, use a loud firm tone." b. "Use language beyond the patient's education level." c. "When you are setting limits, be specific and outline the consequences." d. "Aggressive body language will make the patients respect your position." 10. Childhood-onset conduct disorder is thought to be a precursor to which of the following psychiatric conditions? a. Antisocial personality disorder b. Bipolar disorder c. Schizophrenia d. Dissociative identity disorder

Anger Aggression

Anger --> an emotional response to frustration Aggression --> action or behavior resulting in verbal/physical attack

1ANS: B Persons with PTSD often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for PTSD is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress. 3ANS: D Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased. 4 ANS: A In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system. 5ANS: A The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited. The distracters are more consistent with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.

CHAPTER 16 QUESTIONS QUESTION 1 - A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? A- Trigger flashbacks intentionally in order to help the patient learn to cope with them. B- Explain that the physical symptoms are related to the psychological state. C- Encourage repression of memories associated with the traumatic event. D- Support "numbing" as a temporary way to manage intolerable feelings. CHAPTER 16 QUESTIONS QUESTION 3 - A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents A- visit their child's grave daily. B- maintain their child's room as the child left it 2 years ago. C- keep a place set for the dead child at the family dinner table. D- throw flowers on the lake at each anniversary date of the accident. CHAPTER 16 QUESTIONS QUESTION 4 - Relaxation techniques help patients who have experienced major traumas because they... A- engage the parasympathetic nervous system. B- increase sympathetic stimulation. C- increase the metabolic rate. D-release hormones. CHAPTER 16 QUESTIONS QUESTION 5 - Which assessment finding best supports dissociative fugue? The patient states... A- "I cannot recall why I'm living in this town." B- "I feel as if I'm living in a fuzzy dream state." C- "I feel like different parts of my body are at war." D- "I feel very anxious and worried about my problems."

Somatic Symptom Disorder (SSD)

Goal- increased participation and decision-making, evidence of progress, meet own needs Take Action: Provide explanations, support, and continuous care. Avoid unnecessary procedures.* Provide frequent, brief, and regular visits. Conduct a complete exam (mental and physical).* Avoid disparaging comments. Set reasonable, therapeutic goals.

BINGE EATING DISORDER

Leads to obesity: •Risk for Heart disease, diabetes, HTN Gastrointestinal problems-quantity of food: •Heartburn, dysphagia, bloating, abdominal pain, diarrhea, constipation, urgency, & anal blockage

Eating disorders include: Anorexia nervosa Bulimia nervosa Binge eating

Personality traits may include perfectionism, inflexibility, rule driven, excessive doubt: Obsessive-compulsive disorders* Moodd disorders* Anxiety disorders*

Sexual Abuse:

Rape = nonconsensual activity that involves penetration of vagina, anus with object, body part or oral penetration

Quiet Room

•Purpose: provides an environment of less stimulation, regain control •Must be unlocked!

ADHD Outcomes

•Reduction in: •Hyperactive behaviors •Impulsive behaviors •Development of self-identity •Increase self-esteem •Establish and implement positive coping skills •Increased family functioning •Medications are not curative

Conduct Disorder

•Rules, basic rights of others are continuously violated •At least three criteria from the following categories for at least 6 months: •Aggression to people and/or animals •Destruction of property •Deceitfulness or theft •Serious violations of rules •Main precursor to antisocial personality disorder (display of callousness) à no regret/remorse AT ALL •Academic associations- truancy, disruptiveness leading to failure or expulsion from the school

•Gender identity

•Sense of "maleness" or "femaleness" •Not usually established until a child is 3 years old

PTSD Interventions for Children

•Stage One: •Focus on promoting safety and stabilization of the home environment, stop destructive behaviors •Use developmentally appropriate language and boundary setting •Stage Two: •Focus on memory work and moderating emotional and arousal states •Relaxation exercises (deep-breathing, mindfulness), expression through art and play •Stage Three: •Focus on increasing self-awareness, implementing coping skills, using social support systems •Education of grief process, trauma response

Physical Abuse:

e.g., hitting, kicking, biting, scratching; pushing, shoving, throwing items; threats with weapon; strangulation; shooting at or around

Historical Trauma

•Experiences, commonly shared by communities, that results in emotional and psychological wounds •These wounds pass from generation to generation •May result in PTSD, psychiatric disorders, substance use •Threatens families, communities, cultural structures •Examples (not all-inclusive)- American Indians/Alaska Natives, African-Americans/Black, survivors of the Holocaust

Trauma-Related Disorders in Children Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.

•PTSD •Reactive attachment disorder •Disinhibited social engagement disorder •Examples of causes- adverse childhood experiences, automobile accidents, major illness, natural disasters, war, terrorism •Increased risk in children who have been neglected and/or abused •Subsequent increased risk to abuse others

Neglect: *Neglect will always be on the NCLEX *Older adults are at high risk for violence, particularly when there is significant dependency such as would be expected with dementia or other cognitive impairments. The incorrect responses are not identified as placing an individual at high risk.

e.g., deprivation of food, clothing, shelter; isolation; withholding health/medical care, assistive devices, food, clothing, shelter; canceling medical appointments

Emotional Abuse:

e.g., yelling, screaming, berating, depreciating, threats, coercive control, undue influence, deprivation of emotional connection/warmth, tricking, gaslighting, intimidating, threatening

Somatic Symptom Disorder (SSD) *For SSD, the symptoms ARE real, but they do not actually have a medical diagnosis/disease

•1+ distressing symptoms •Excessive thoughts, anxiety & behaviors around symptoms, or health concerns •NO MEDICAL DIAGNOSIS •Suffering is UNIQUE AND INDIVIDUALIZED •High level of functional impairment

Factitious Disorders ("Munchhausen's" & "Munchhausen-by-Proxy")

•1. Factitious disorder imposed on self •2. Factitious disorder imposed on another •Lie about or mimic symptoms •Hurt themselves to bring on symptoms •Alter diagnostic tests (contaminate a urine sample or tamper with a wound to prevent healing) •May undergo painful or risky tests and operations to obtain sympathy and special attention given to people who are ill

•Secondary Prevention: Aims to reduce the impact after abuse occurs

•23 certified crisis centers in Oklahoma •OK HB 2526 Police Lethality Assessment at the scene of IPV to prevent death •OK SB 17 Domestic violence providing certain protocol process •OK SB 1290 Medical Care Provider Protection Act

Family Therapy

•APRNs may be qualified to conduct family therapy •In some circumstances family therapy is not helpful if: •therapeutic environment is not safe when information is shared. •the environment is hostile or high levels of anxiety. •there is a lack of willingness to be honest. •there is an unwillingness to maintain confidentiality.

Nurse Skill Set for Roles of "Helper" and "Facilitator"

•Active listening •Positive attitude •Nonjudgmental •Critical observations/assessments •Communication for discussion, facilitating and reporting •Problem-solving approach in acute family need •Counseling at the advanced-practice level

PARAPHILIC DISORDERS***

•Acts or sexual stimuli that are outside of what society considers normal, but are required for some individuals to experience desire, arousal, and orgasm •Symptoms last at least 6 months

•Diagnosis: Sexual dysfunction

•Altered body function from medication •Biopsychosocial alteration of sexuality •Psychosocial abuse from significant other

IDD Outcomes **accommodate to THEIR routine

•Appropriate use of verbal language •Engage in simple social interactions for short periods of time without frustration •Accept assistance and feedback without frustration •Refrain from impulsivity towards self or others when frustrated •Families and caregivers acknowledge existence IDD and its affects on routines

Take action:

•Assess the individual (e.g., risk assessment tools) •Assess the environment (e.g., lighting, noise) •Early intervention that is the least restrictive •Approach with respect, dignity, and empathy •Communicate clearly, calmly, and honestly •Encourage seeking assistance when emotions or tensions increase •Respond to the communicated problems or concerns •Offer several options and set clear limits and boundaries •Maintain your safety Personal space Notify the supervisor and security when the need arises

SEXUAL HISTORY

•Be aware of your personal feelings about sexuality •Views about sexuality: based on beliefs, traditions, spiritual and religious teachings, parental views, societal attitudes •Be "neutral" describing the sexual behaviors •Use matter-of-fact approach (See Table 20.2 Assessment, p. 379) •Open-ended questions: don't assume •EXAMPLE: "Tell me about your sexual partners" •Don't assume male is may be male or both

Temperament- it's the how

•Behavior used to cope with the environment •Begins in infancy •Caregiver's role critically important •Powerful predictor of behaviors later in life (e.g., substance use and abuse)

1Answer: B Patients with somatic symptom disorders go from one health care provider to another trying to establish a physical cause for their symptoms. When a psychological basis is suggested and a referral for counseling offered, these patients reject both. 2Answer: B Psychoanalytical theory suggests conversion reduces anxiety through production of a physical symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the operative defense mechanism in this disorder. While some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation, there is no actual alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting that only dependency needs are of concern, or suggest conscious motivation (conversion operates unconsciously). 3Answer: B Patients with illness anxiety disorder have fears of serious medical problems, such as cancer or heart disease. These fears persist despite medical evaluations and interfere with daily functioning. There are no complaints of pain. There is no evidence of factitious or conversion disorder. 4Answer: D The key is the only fully accurate statement. Somatic symptom disorders involve expression of stress through bodily symptoms and are not under voluntary control or culture bound. Factitious disorders are under voluntary control. See relationship to audience response question. 5Answer: B Questioning the evidence is a cognitive reframing technique. Identifying causes other than the feared disease can be helpful in changing distorted perceptions. Distraction by changing the subject will not be effective. 6Answer: C Somatic symptom disorders are commonly associated with complicated reactions to stress. These reactions are accompanied by muscle tension and pain. Relaxation can diminish the patient's perceptions of pain and reduce muscle tension. The distracters are modalities useful in treating selected anxiety disorders.

•CHAPTER 17 QUESTIONS •Question 1 - A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder. Care planning is facilitated by understanding that the patient will probably... • •A- readily seek psychiatric counseling. •B- be resistant to accepting psychiatric help. •C- attend psychotherapy sessions without encouragement. •D- be eager to discover the true reasons for physical symptoms. •CHAPTER 17 QUESTIONS •Question 2 - A patient has blindness related to conversion (functional neurological) disorder but is unconcerned about this problem. Which understanding should guide the nurse's planning for this patient? • •A- The patient is suppressing accurate feelings regarding the problem. •B- The patient's anxiety is relieved through the physical symptom. •C- The patient's optic nerve transmission has been impaired. •D- The patient will not disclose genuine fears. • •CHAPTER 17 QUESTIONS •Question 3 - A patient reports fears of having cervical cancer and says to the nurse, "I've had Pap smears by six different doctors. The results were normal, but I'm sure that's because of errors in the laboratory." Which disorder would the nurse suspect? • •A- Conversion (functional neurological) disorder •B- Illness anxiety disorder (hypochondriasis) •C- Somatic symptom disorder •D- Factitious disorder • •CHAPTER 17 QUESTIONS •Question 4 - What is an essential difference between somatic symptom disorders and factitious disorders? • •A- Somatic symptom disorders are under voluntary control, whereas factitious disorders are unconscious and automatic. •B- Factitious disorders are precipitated by psychological factors, whereas somatic symptom disorders are related to stress. •C- Factitious disorders are individually determined and related to childhood sexual abuse, whereas somatic symptom disorders are culture bound. •D- Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization. • •CHAPTER 17 QUESTIONS •Question 5 - A patient says, "I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? • •A- "You do not have a brain tumor. The more you talk about it, the more it reinforces your belief." •B- "Let's see if there are any other possible explanations for your vomiting." •C- "You seem so worried. Let's talk about how you're feeling." •D- "We need to talk about something else." • •CHAPTER 17 QUESTIONS •Question 6— Which treatment modality should a nurse recommend to help a patient diagnosed with a somatic symptom disorder to cope more effectively? • •A- Flooding •B- Response prevention •C- Relaxation techniques •D- Systematic desensitization

1Answer: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis. 2ANS: D The patient's history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia. 3Answer: D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patient's physiological integrity. The other body systems are not initially involved in the refeeding syndrome. 4Answer: B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private. 5Answer: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg. 6Answer: C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.

•CHAPTER 18 QUESTIONS •Question 1 - Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? • •A- Weight, muscle, and fat congruence with height, frame, age, and sex •B- Calorie intake is within required parameters of treatment plan •C- Weight reaches established normal range for the patient •D- Patient expresses satisfaction with body appearance • • •CHAPTER 18 QUESTIONS •Question 2 - A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? • •A- Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss •B- Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia •C- Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia •D- Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia • •CHAPTER 18 QUESTIONS •Question 3 - The nursing care plan for a patient diagnosed with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? • •A- Renal •B- Endocrine •C- Integumentary •D- Cardiovascular • • •CHAPTER 18 QUESTIONS •Question 4 - An appropriate intervention for a patient diagnosed with bulimia nervosa who binges and purges is to teach the patient... • •A- to eat a small meal after purging. •B- not to skip meals or restrict food. •C- to increase oral intake after 4 PM daily. •D- the value of reading journal entries aloud to others. • • •CHAPTER 18 QUESTIONS •Question 5 - One bed is available on the inpatient eating-disorder unit. Which patient should be admitted to this bed? The patient whose weight decreased from... • •A- 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg •B- 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg •C- 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg •D- 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg • •CHAPTER 18 QUESTIONS •Question 6 - A nurse provides health teaching for a patient diagnosed with bulimia nervosa. Priority information the nurse should provide relates to • •A- self-monitoring of daily food and fluid intake. •B- establishing the desired daily weight gain. •C- how to recognize hypokalemia. •D- self-esteem maintenance.

Autism Spectrum Disorders (ASD)- diagnosis 1st 3 years of life

•Neurobiological and developmental disability (verbal communication skills are lacking) •Possible theories of specific etiology: •Single gene direct inheritance •Immune dysregulation/neuroinflammation •Damage to cellular tissue •Environmental factors •Affects brain development for social interaction and communication skills •Traits: repetition and fixation in speech and use of objects, over adherence to routines/rituals, hypo- or hyperactivity to sensory input, resistance to change

MEDICAL CONDITIONS & SEXUAL DYSFUNCTION

•Endocrine (DM, Hypothyroidism) •Vascular (HTN, Stroke) •Genital (endometriosis) •Systematic (Renal failure, Cancer) •Psychiatric (Depression, PTSD) *SSRI's •Surgical (Prostatectomy)

•Gender dysphoria

•Feelings of unease about maleness or femaleness Identifies with the opposite biological sex: •No longer a "disorder" in DSM-5 (2012) •May begin in childhood •Some persist to adulthood •High rate of depression & suicide •Possible hormone therapy •Sexual reassignment surgery 24

PARAPHILIC SEXUAL DISORDERS "Paraphilias"

•Fetishism (inanimate object - mostly men) •Pedophilic disorder (sexual interest in children) illegal •Exhibitionism (displays genitals) illegal •Voyeurism (watching others) if no consent = illegal •Transvestic (not related to sexual desire or orientation) •Sexual Sadism /Masochism (inflict pain or humiliation) •Frotteurism (rubbing against other people)

GENDER IDENTITY

•Gender identity is a person's internal sense of being a man/male, woman/female, both, neither, or another gender

***Indicators of Abuse: *NEVER ASK VICTIMS "WHY" STATEMENTS *PERPETRATORS MAY CONTROL FAMILY FINANCES AND ARE USUALLY PATHOLIGICALLY JEALOUS

•Head, neck, facial, back injuries, bruises •"Bathing suit" injuries •Internal injuries or fracture: jaw, arms, pelvis, clavicle, ribs •old and new •Burns •Defensive wounds •Psychological reactions •Miscarriage •Injuries to a pregnant woman •Hoarseness •Stiff neck, marks on neck •Stroke, Post-concussive syndrome in young women •Traumatic brain injuries •Repeated visits to health practitioners •*Survivor may verbalize problems, but usually doesn't disclose extent or offender

Intellectual Development Disorder (IDD) ("new word for mental retardation")

•IDD Background •Deficit in three areas of function: •Deficit one: intellectual functioning •Deficit two: social functioning •Deficit three: activities of daily living functioning •Etiology: •Biological factors: heredity, problems during pregnancy, problems in perinatal development Psychosocial factors: poor environment, lack of fostering language and social development

BULIMIA

•Ideal body weight •Swollen parotid glands •Electrolyte imbalances •Cardiac arrhythmias •Esophageal ulcers & tears •Abdominal pain •Usually eats alone •Increased mood while eating •Decreased mood AFTER eating •May sleep after eating •Vomits after binging is over

Attention Deficit Hyperactivity Disorder (ADHD) TX OF ADHD: Methylphenidate (Ritalin) + Amphetamine (Adderall)

•Inattention, impulsivity, hyperactivity to varying degrees in an individual, impeding development •Criteria: •Symptoms present in two settings (e.g., home and school) •Onset prior to age 12 years •Three types: inattentive, hyperactive-impulsive, combination (most common) •Exact etiology unknown: hereditary; genetic abnormalities; insufficiency of dopamine or serotonin; excess of norepinephrine •Comorbidity: oppositional defiant disorder, conduct disorder, disruptive mood dysregulation disorder, anxiety ADHD Assessment •Hyperactive-Impulsive: difficulty taking turns and maintaining relationships, poor social boundaries, intrusion, interrupting others •Inattentive: distractibility, disorganization, unable to complete tasks,easily bored,lose objects, frequent prompts •Levels of: physical activity, attention span, frustration tolerance, impulse control, talkativeness •Social skills, relationships, problem-solving skills, performance in school •Associated comorbidities

•Diagnosis: Ineffective sexuality pattern

•Lack of significant other •Conflicts with sexual orientation •Impaired relationship with significant other •Knowledge deficit about alternative responses to illness

Illness Anxiety Disorder -> AKA hypochondriac

•Misinterpretation of physical sensations •Preoccupation with having or acquiring serious illness for at least 6 months •High anxiety about health •Excessive health-related behaviors or maladaptive avoidance •May be care-seeking or care-avoidant

Adverse Childhood Experiences •"...stressful or traumatic events, including abuse and neglect...strongly related to the development and prevalence of a wide range of health problems throughout a person's lifespan, including those associated with substance abuse" (SAMHSA, 2017)

•Neglect •Abuse (emotional, physical, sexual) •Domestic violence •Parental separation •Incarceration

EATING DISORDERS: THEORIES

•Neurobiological Altered neurotransmitters - Serotonin, norepinephrine and dopamine •Neuroendocrine: Abnormalities noted •Causal relationship possible •May be result of starvation or abnormal eating behavior •Genetic models •Strong genetic link for eating disorders •Psychological models: •Core psychopathology: Feelings of •Low self esteem •Self-doubts about personal worth •Feelings produce harsh self-judgment focused on weight •Family dynamics - criticism, hostility and overprotection. •Sociocultural models •Incidence of eating disorders increases in societies in which women have a choice in social roles •Society values "thin as in"

Conversion Disorder unaware that their symptoms may be an emergency/ conversion disorder

•Neurological symptoms in the absence of a neurological diagnosis •Deficits in voluntary motor or sensory functions •Common symptoms—paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or •episodes resembling epilepsy

•Primary Prevention: Prevent abuse/violence before it occurs -> TEACHING

•Nurse home visitation programs with high-risk families after birth of babies •Early childhood education related to relationships, consent; adolescent relational programs; anti-bullying programs •Legislation

PTSD in Adults

•Occurs after a traumatic event, outside the range of the individual's typical response •Examples of causes- military combat, prisoner of war, natural or human disasters, crime-related events, life-threatening illness •Symptoms commonly occur within 3 months after the event, but may occur years later •Estimated majority of individuals have experienced an average of 5 traumatic events in their lifetime •Women twice as likely to develop PTSD •Comorbidities- increased adverse childhood experiences, depression, anxiety, sleep disorders, dissociative disorders, substance use as self-medication

Oklahoma Law

(1) Abuse of a Child, Vulnerable Individual, Older Adult •Legally required to report if suspected (follow facility protocol for reporting) (2) For intimate partner violence, the licensed nurse must: •Screen (follow facility protocol) •Offer a choice to report to law enforcement; inform what will happen •Offer referrals •Document screening results, survivor's choice to report to law enforcement, referrals given (3) Know the law that protects you (OK SB 1290) •Assault protection for all healthcare workers •Increases penalties •Mandatory signage in facilities

•Abuse and Violence Prevention

*GREATEST RISK FOR VIOLENCE IS WHEN INDIVIDUAL TRIES TO LEAVE *Rape is the 2nd most violent crime *Abuse and sexual assault can happen to ANY gender, race, age, ethnicity

6. c; 7. b; 8. a; 9. c; 10. b

6. Diane, a 63-year-old mother of three, was brought to the community psychiatric clinic. Diane and her son had a bitter fight over finances. Ever since, Diane has been complaining of "a severe pain in my neck." She has seen several doctors who cannot find a physical basis for the pain. The nurse knows that: a. Showing concern for Diane's pain will increase her obsessional thinking. b. Diane's symptoms are manipulative and under conscious control. c. Diane believes there is a physical cause for the pain and will resist a psychological explanation. d. Diane is trying to make her son feel bad about the argument. 7. Conversion disorder is described as an absence of a neurological diagnosis that manifests in neurological symptoms. Channeling of emotions, conflicts, and stressors into physical symptoms is thought to be the cause of conversion disorder. Which statement is true? a. People with conversion disorder are extremely upset about often dramatic symptoms. b. Abnormal patterns of cerebral activation have been found in individuals with conversion disorder. c. An organic cause is usually found in most cases of conversion disorder. d. Symptoms can be turned off and on depending on the patient's choice. 8. Melanie is a 38-year-old female admitted to the hospital to rule out a neurological disorder. The testing was negative, yet she is reluctant to be discharged. Today she has added lower back pain and a stabbing sensation in her abdomen. The nurse suspects a factitious disorder in which Melanie may: a. Consciously be trying to maintain her role of a sick patient. b. Not recognize her unmet needs to be cared for. c. Protect her child from illness. d. Recognize physical symptoms as a coping mechanism. 9. You are caring for Yolanda, a 67-year-old patient who has been receiving hemodialysis for 3 months. Yolanda reports that she feels angry whenever it is time for her dialysis treatment. You attribute this to: a. Organic changes in Yolanda's brain. b. A flaw in Yolanda's personality. c. A normal response to grief and loss. d. Denial of the reality of a poor prognosis. 10. Lucas is a nurse on a medical floor caring for Kelly, a 48-year-old patient with newly diagnosed type 2 diabetes. He realizes that depression is a complicating factor in the patient's adjustment to her new diagnosis. What problem has the most potential to arise? a. Development of agoraphobia b. Treatment nonadherence c. Frequent hypoglycemic reactions d. Sleeping rather than checking blood sugar 1. b; 2. d; 3. d, e; 4. d; 5. d; 6. c; 7. b; 8. a; 9. c; 10. b

6. d; 7. a, d; 8. d; 9. b; 10. c

6. In understanding the role of victim and perpetrator, the act of evidence collection is enhanced. What knowledge base can be helpful in caring for the injured victim? a. Legal aspects b. Experience testifying in court c. Collaboration with law practitioners d. Medical-surgical nursing skills 7. For a competency hearing, the psychiatric forensic nurse has been asked to evaluate an incarcerated patient who has mental health problems. As the patient is being considered for sentencing, what is the psychiatric forensic nurse's role? Select all that apply. a. Assessing the patient for level of competency b. Determining whether the patient is guilty or innocent c. Helping to determine the length of the sentence d. Completing a formal report to the court e. Becoming an advocate for the incarcerated patient 8. To determine a patient's legal sanity or competency, the psychiatric forensic nurse must assess all of the following, except a. The patient's ability to distinguish right from wrong regarding the act committed b. The patient's capacity to understand the nature of the act committed c. The evidence with respect to the defendant's mental state at the time the act was committed d. The patient's social network 9. You are caring for Naomi, who has been arrested and is found to be at risk for alcohol and drug use. Which approach is the most useful in treating Naomi? a. Recommending that the patient receive treatment when released from jail b. Providing an immediate drug/alcohol treatment plan c. Immediately withdrawing all medications d. Isolating the patient until her withdrawal from drugs is complete 10. Which activity does a correctional nurse not fulfill within the corrections setting? a. Making nursing assessments b. Maintaining proper safety procedures c. Providing psychotherapy d. Documenting patient progress

6. b; 7. a; 8. a, b, d; 9. a; 10. c

6. Obesity can be the end result of a binge-eating disorder. The nurse understands that the best treatment option in persons with a binge-eating disorder is a. Bariatric surgery b. Coping strategies c. Avoidance of public eating d. Appetite suppression medications 7. Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina of the following: a. "I need to go through the belongings you have brought with you." b. "You can use the scale in the back room when you need to." c. "You will be eating five times a day here." d. "The daily structure is based around your desire to eat." 8. Safety measures are of concern in treating eating disorders. Patients with anorexia nervosa are supervised closely to monitor the following: Select all that apply. a. Foods that are eaten b. Attempts at self-induced vomiting c. Relationships with other patients d. Weight 9. Malika has been overweight all her life. Now an adult, she has health problems related to excessive weight. Seeking weight-loss assistance at a primary care facility, Malika is surprised when the nurse practitioner suggests the following: a. A trial of SSRI antidepressant therapy b. Mild exercise to start, increasing in intensity over time c. Removing snack foods from the home d. Medication treatment for hypertension 10. Malika agrees to try losing weight according to the nurse practitioner's outlined plan. Additional teaching is warranted when Malika states that a. "I am willing to admit that I am depressed." b. "Psychotherapy will be a part of my treatment." c. "I prefer to have a gastric bypass rather than use this plan." d. "My comorbid conditions may improve with weight loss."

6. d; 7. c; 8. c; 9. c; 10. a

6. The stress of being raped often results in suffering similar to people who have witnessed a murder or had a physiological reaction to trauma, resulting in which of the following? a. Posttraumatic stress disorder b. Anxiety c. Depression d. All of the above 7. A young woman named Carly was raped after closing shift behind the restaurant where she works. Six months have passed and Carly has not been able to return to work, refuses to go out to eat, and feels that she has less value as a woman now that she has been raped. Carly's clinical presentation suggests: a. Reexperiencing b. Hyperalertness c. Avoidance d. Physical effects 8. Ron is a victim of assault and has revealed to his family and friends the fact that he was raped. The family reacts with horror and disgust, and the nurse caring for Ron recognizes that a. Ron's family is being judgmental. b. Ron's family should leave the hospital. c. Ron's family will also need support. d. Ron's family's dynamics are dysfunctional. 9. Perpetrators of sexual assault are often incarcerated but frequently do not undergo therapy. Samuel, convicted of rape and sentenced to 15 years in prison, has asked to see a therapist. The psychiatric nurse practitioner is surprised to learn of the request, as many perpetrators a. Boast of their assault history. b. Feel regret and remorse. c. Do not acknowledge the need for change. d. Are unable to recognize rape as a crime. 10. You are working at a telephone hotline center when Abby, a rape victim, calls. Abby states she is afraid to go to the hospital. What is your best response? a. "I'm here to listen, and we can talk about your feelings." b. "You don't need to go to the hospital if you don't want to." c. "If you don't go to the hospital, we can't collect evidence to help convict your rapist." d. "Why are you afraid to seek medical attention?"

6. a; 7. c; 8. c; 9. a; 10. b

6. Which patient has the greatest risk for suicide? a. A patient who expresses the inability to stop searching the internet for child pornography. b. A patient who reports having lost interest in having a sexual relationship with his wife. c. A patient with a history of exposing himself to female strangers on the bus. d. A patient whose attraction to prepubescent girls has increased. 7. When Melissa was a small child, she insisted that she was a boy, refused to wear dresses, and wanted to be called Mitch. As Melissa reached puberty, she no longer displayed a desire to be male. This change in identity is considered a. Gender dysphoria b. Reaction formation c. Normal d. Early transgender syndrome 8. Phillip, a 63-year-old male, has exposed his genitals in public for all of his adult life, but the act has lost some of the former thrill. A rationale for this change in his experience may be a. An increasing sense of shame b. Disgust over his lack of control c. Desire waning with age d. Progression into actual assault 9. A male arrested for inappropriate sexual contact in a subway car denies the allegation. On interviewing the man, the nurse suspects frotteuristic disorder due to his a. Lack of relationships b. Overall aggressive nature c. Criminal history including robbery d. Intense hatred of women 10. Pedophilic disorder is the most common paraphilic disorder where adults who have a primary or exclusive sexual preference for prepubescent children. A subset of this disorder is termed hebephilia and is defined as attraction to a. Infants b. Pubescent individuals c. Teens between the ages of 15 and 19 d. Males only

Assessment, Nursing Diagnosis, Outcomes- Children

Assessment: •observation -interaction as part of the Mental Status Exam •Play activities •Rapid changes in behavior •Developmental or trauma-based screening tools Nursing Diagnosis •Risk for impaired parent/child attachment •Risk of delayed development Outcomes •decreased/diminished symptoms, self-control, use of social supports, maintenance of relationships

1ANS: C Holding the hand of another person suggests relatedness. Usually, a child diagnosed with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders. 2ANS: C Central nervous system (CNS) stimulants are the drugs of choice for treating children diagnosed with ADHD. Methylphenidate and mixed amphetamine salts are most commonly used. None of the other drugs are psychostimulants used to treat ADHD. 3ANS: C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications. 4ANS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. Occasional toileting accidents and crying when separated from a parents are expected findings for a 3-year-old. Interrupting or intruding on others are assessment findings associated with ADHD. 5ANS: A Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk-enhancing.

CHAPTER 11 & 21 QUESTIONS QUESTION 1 - Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child... A- plays with one toy for 30 minutes. B- repeats words spoken by a parent. C- holds the parent's hand while walking. D- spins around and claps hands while walking. CHAPTER 11 & 21 QUESTIONS QUESTION 2 - A nurse will prepare teaching materials for the parents of a child newly diagnosed with ADHD. Information will focus on which medication likely to be prescribed? A- Paroxetine B- Imipramine C- Methylphenidate D- Carbamazepine CHAPTER 11 & 21 QUESTIONS QUESTION 3 - What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for ADHD? A- Dystonia, akinesia, and extrapyramidal symptoms B- Bradycardia and hypotensive episodes C- Sleep disturbances and weight loss D- Neuroleptic malignant syndrome CHAPTER 11 & 21 QUESTIONS QUESTION 4 - A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child A- has occasional toileting accidents. B- interrupts or intrudes on others. C- cries when separated from a parent. D- continuously rocks in place for 30 minutes. CHAPTER 11 & 21 QUESTIONS QUESTION 5- Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? A- The child has been raised by a parent with recurring major depressive disorder. B- The child's best friend was absent from the child's birthday party. C- The child was not promoted to the next grade one year. D- The child moved to three new homes over a 2-year period.

1ANS: C A blended family is made up of members from two or more unrelated families. It is not a nuclear family because a stepchild is present. It is not an extended family, because there are only two generations present. Homogeneous is not a family type. 2ANS: D The information almost universally obtained is that the family is under stress associated with having a mentally ill member. This stress lowers the family's level of functioning in at least one significant way. Stress does not necessarily mean the family has become dysfunctional. 3ANS: B Interactions among all family members are the raw material for family problem solving. By observing interactions, the nurse can help the family make its own assessments of strengths and deficits. The other options are narrower in scope when compared with the correct option. 4ANS: B It is important to understand family characteristics, particularly in a family under stress. Expression of feelings is an important aspect of assessment of the family's function (or dysfunction). The distracters relate more to outcome identification and planning interventions, both of which should be delayed until the assessment is complete. 5ANS: B Scapegoating projects blame for family problems onto a member who is less powerful. The purpose of this projection is to distract from issues or dysfunctional behaviors in the members of the family.

CHAPTER 35 QUESTIONS QUESTION 1 - A married couple has two biologic children who live with them as well as a child from the wife's first marriage. What type of family is evident? A- Homogeneous B- Extended C- Blended D- Nuclear CHAPTER 35 QUESTIONS QUESTION 2 - Which information is the nurse most likely to find when assessing the family of a patient with a serious mental illness? A- The family exhibits many characteristics of dysfunctional families. B- Several family members have serious problems with their physical health. C- Power in the family is maintained in the parental dyad and rarely delegated. D- Stress from living with a mentally ill member has challenged the family's function. CHAPTER 35 QUESTIONS QUESTION 3 - A parent is admitted to a unit for treatment of addictions. The patient's spouse and adolescent children participate in a family session. What is the most important aspect of this family's assessment? A- Spouse's codependent behaviors B- Interactions among family members C- Patient's reaction to the family's anger D- Children's responses to the family sessions CHAPTER 35 QUESTIONS QUESTION 4 - A parent is admitted to a unit for treatment of addictions. The patient's spouse and adolescent children attend a family session. Which initial assessment question should the nurse ask of family members? A- "What changes are most important to you?" B- "How are feelings expressed in your family?" C- "What types of family education would benefit your family?" D- "Can you identify a long-term goal for improved functioning?" CHAPTER 35 QUESTIONS QUESTION 5 - Which scenario best illustrates scapegoating within a family? A- The identified patient sends messages of aggression to selected family members. B- Family members project problems of the family onto one particular family member. C- The identified patient threatens separation from the family to induce feelings of isolation and despair. D- Family members give the identified patient nonverbal messages that conflict with verbal messages.

1. b; 2. a; 3. a, c, e; 4. d; 5. a;

Chapter 18 Review 1. Which patient statement acknowledges the characteristic behavior associated with a diagnosis of pica? a. "Nothing could make me drink milk." b. "I'm ashamed of it, but I eat my hair." c. "I haven't eaten a green vegetable since I was 3 years old." d. "I regurgitate and rechew my food after almost every meal." 2. In evaluating an eating disorder, what physical criterion for hospital admission would you consider? a. A daytime heart rate of less than 50 beats per minute b. An oral temperature of 100°F or more c. 90% of ideal body weight d. Systolic blood pressure greater than 130 mm Hg 3. In considering the need for monitoring, which intervention should the nurse implement for a patient with anorexia nervosa? Select all that apply. a. Provide scheduled portion-controlled meals and snacks. b. Congratulate patients for weight gain and behaviors that promote weight gain. c. Limit time spent in the bathroom during periods when the patient is not under direct supervision. d. Promote exercise as a method to increase appetite. e. Observe patient during and after meals/snacks to ensure that adequate intake is achieved and maintained. 4. Which intervention will promote independence in a patient being treated for bulimia nervosa? a. Have the patient monitor daily caloric intake and intake and output of fluids. b. Encourage the patient to use behavior modification techniques to promote weight gain behaviors. c. Ask the patient to use a daily log to record feelings and circumstances related to urges to purge. d. Allow the patient to make limited choices about eating and exercise as weight gain progresses. 5. Which patient statement supports the diagnosis of anorexia nervosa? a. "I'm terrified of gaining weight." b. "I wish I had a good friend to talk to." c. "I've been told that I drink way too much alcohol." d. "I don't get much pleasure out of life anymore."

1. a, b, d, e; 2. b; 3. a, b, d; 4. a, b, c, d;

Chapter Review 27 1. Which individuals are most at risk for displaying aggressive behavior? Select all that apply. a. An adolescent embarrassed in front of friends. b. A young male who feels rejected by the social group. c. A young adult depressed after the death of a friend. d. A middle-aged adult who feels that concerns are going unheard. e. A patient who was discovered telling a lie. 2. A newly admitted male patient has a long history of aggressive behavior toward staff. Which statement by the nurse demonstrates the need for more information about the use of restraint? a. "If his behavior warrants restraints, someone will stay with him the entire time he's restrained." b. "I'll call the primary provider and get an as-needed (prn) seclusion/restraint order." c. "If he is restrained, be sure he is offered food and fluids regularly." d. "Remember that physical restraints are our last resort." 3. Which intervention(s) should the nurse implement when helping a patient who expresses anger in an inappropriate manner? Select all that apply. a. Approach the patient in a calm, reassuring manner. b. Provide suggestions regarding acceptable ways of communicating anger. c. Warn the patient that being angry is not a healthy emotional state. d. Set limits on the angry behavior that will be tolerated. e. Allow any expression of anger as long as no one is hurt. 4. Which guidelines should direct nursing care when deescalating an angry patient? Select all that apply. a. Intervene as quickly as possible. b. Identify the trigger for the anger. c. Behave calmly and respectfully. d. Recognize the patient's need for increased personal space. e. Demands are agreed to as long as they will not result in harm to anyone.

1. b; 2. a, b, c, e; 3. b; 4. d; 5. a, b, c, d;

Chapter Review 28 1. Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work." 2. Which problem is observed in children who regularly witness acts of violence in their family? Select all that apply. a. Phobias b. Low self-esteem c. Major depressive disorder d. Narcissistic personality disorder e. Posttraumatic stress disorder 3. What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with older adults. 4. What safety-related responsibility does the nurse have in any situation of suspected abuse? a. Protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties, but especially the patient. d. Report suspected abuse to the proper authorities. 5. The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? Select all that apply. a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter e. The hospital emergency department

1. b; 2. d; 3. b; 4. a, b, d, e; 5. a;

Chapter Review 29 1. Which statement made by a sexually assaulted patient strongly suggests the drug gamma-hydroxybutyric acid (GHB) was involved in the attack? a. "I remember everything that happened but felt too tired to fight back." b. "The drink I was given had a salty taste to it." c. "They tell me I was unconscious for 24 hours." d. "I heard that I was fighting the nursing staff and saying that they were trying to kill me." 2. Considering the guilt that women feel after being sexually assaulted, which nursing assessment question has priority? a. "Do you want the police to be called?" b. "Did you recognize the person who assaulted you?" c. "Do you have someone you trust that can stay with you?" d. "Do you have any thoughts about harming yourself?" 3. Which statement is an accurate depiction of sexual assault? a. Rape is a sexual act. b. Most rapes occur in the home. c. Rape is usually an impulsive act. d. Women are usually raped by strangers. 4. Which signs and symptoms are associated with rape-trauma and rape-trauma response? Select all that apply. a. Outbursts of anger b. Major depressive disorder c. Auditory hallucinations d. Flashbacks e. Amnesia for the event 5. Which racial identification places a woman at the greatest risk of being sexually assaulted in her lifetime? a. Multiracial b. American Indian c. Black non-Hispanic d. White

1. a, b, d, e; 2. b; 3. d; 4. b, c, d; 5. c;

Chapter Review 33 1. The forensic nurse examiner is attempting to reconstruct the mental state of an individual accused of a hit-and-run automobile accident. Which question or questions would help to achieve that goal? Select all that apply. a. "Were you under the influence of illegal substances at the time of the accident?" b. "What were you feeling when you realized you had hit someone crossing the street?" c. "Have you ever been involved in a hit-and-run accident before?" d. "Can you remember the events leading up to the accident?" e. "Had you and your friends been drinking before the accident?" 2. A forensic nurse examiner is interviewing an individual accused of a homicide. Which question should the nurse ask in preparation for a possible legal insanity defense? a. "Have you ever been told that you are intellectually deficient?" b. "Do you ever hear voices that no one else can hear?" c. "What were you doing the day the crime was committed?" d. "Did you know the individual who was murdered?" 3. Which nurse would qualify as a fact witness in a case dealing with a physically abused young child? a. A psychiatric nurse b. A sexual assault nurse examiner nurse c. An emergency room nurse d. A pediatric intensive care unit nurse 4. Which intervention focused on children supports the Healthy People 2030 goals related to injury and violence prevention? Select all that apply. a. Screening middle school-aged children for evidence of bullying b. Identifying risk-taking behaviors among high school students that often result in injury c. Holding a focus group discussion regarding the reasons why students bring weapons onto school property d. Holding a community forum to identify the main sources of violence to which children are exposed e. Screening to determine the prevalence of unprotected sex 5. Forensic nursing combines scientific knowledge and inquiry in an effort to serve a. Victims of crime b. Perpetrators of violence c. Victims and perpetrators of crime d. Families of crime victims

DO document:

DO DOCUMENT: •Document date, time, place, why person seen, what person says happened and when, with quotes •Document observations in accurate detail with measurements as needed •Take pictures with permission and/or use a body map •Carefully explain procedures •Document how treated, referrals made (e.g., to supervisor, law enforcement, crisis services) •Document short-term safety plan

Avoid document

Legal terms "Alleged," "perpetrator," "offender" Diagnoses "Intimate partner violence," "child abuse" Interpretations of data or cast doubt "Patient claims" EX good document: •Patient states that early this morning his boyfriend hit him. •The patient stated, "My boyfriend kicked and punched me." •Document physical injuries including size, color description, location (e.g., "Purple bruise over left eye, approximately 6 cm long and 3 cm wide")

Assessment

Level of anxiety Coping Available supports Signs & symptoms of emotional or physical trauma Rape-trauma syndrome History of abuse and violence Weapons available to carry out violence (access) Threats: written, verbal, digital Possibility of date rape drugs (e.g., GHB, Rohypnol, Ketamine) Labs as needed (e.g., STDs, HIV)

ANOREXIA

SYMPTOMS •Terror of gaining weight •Preoccupation with food •Distorted body image •Rigorous exercise routines •Purging (laxatives, diuretics, vomit) •Extreme caloric intake restriction CLINICAL PRESENTATION: ANOREXIA •Body wt. less than 85% of expected •Amenorrhea •Lanugo •Bradycardia •Hypotension •Cardiovascular abnormalities (K+) •Bone density CRITERIA FOR HOSPITALIZATION: - ANOREXIA •Wt. loss > 30% in 6 months •Rapid decline in wt. •No wt. gain with outpatient treatment •Severe hypothermia or dehydration •Systolic BP < 70 mm Hg •Hypokalemia (< 3mEq/L) •EKG changes (arrhythmias) NURSING CARE: ANOREXIA •Monitor VS, fluid & food intake, I&Os •Monitor electrolytes •Monitor for at least 1 hour post meals •Discourage excessive exercise •Support self-acceptance

1Answer: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care. 2Answer: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously. Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations. 3Answer: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping. 4Answer: C Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder. 5Answer: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims' families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patient's disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel. See relationship to audience response question.

•CHAPTER 20 QUESTIONS •Question 1 - Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should • •A- develop an understanding of human sexual response. •B- assess the patient's sexual functioning and needs. •C- acquire knowledge of the patient's sexual roles. •D- clarify own personal values about sexuality. • •CHAPTER 20 QUESTIONS •Question 2 - A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, "Without the red teddies, I am not interested in sex." The nurse can assess this as consistent with • •A- exhibitionism. •B- voyeurism. •C- frotteurism. •D- fetishism. • • •CHAPTER 20 QUESTIONS •Question 3 - An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? • •A- Defensive coping •B- Sexual dysfunction •C- Ineffective sexuality pattern •D- Disturbed sensory perception, tactile • • •CHAPTER 20 QUESTIONS •Question 4 - Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? • •A- Homosexual •B- Ritualistic behaviors •C- Seeks access to children •D- Self-confident professional • •CHAPTER 20 QUESTIONS •Question 5 - A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest? • •A- Determine the nature and extent of the coach's sexual disorder. •B- Assess the coach's potential for suicide or other self-harm. •C- Assess the coach's self-perception of problem and needs. •D- Determine whether other children were harmed.

1Answer: C Patients who are delusional, hyperactive, impulsive, or predisposed to irritability are at higher risk for violence. The patient in the correct response has the greatest disruption of ability to perceive reality accurately. People who feel persecuted may strike out against those believed to be persecutors. The other patients have better reality-testing ability. 2Answer: B A patient gains feelings of security if he or she sees others are present to help with control. The nurse gives a simple direction, honestly states what is going to happen, and reassures the patient that the intervention will be helpful. This positive approach assumes the patient can act responsibly and will maintain control. Physical control measures are used only as a last resort. 3Answer: B A history of prior aggression or violence is the best predictor of who may become violent. Patients with anxiety disorders are not particularly prone to violence unless panic occurs. Patients experiencing hopelessness and powerlessness may have coexisting anger, but violence is uncommon. Patients with paranoid delusions are at greater risk for violence than those with bizarre somatic delusions. 4Answer: D The description of the patient's behavior shows the classic signs of someone whose potential for aggression is increasing. 5Answer: C Olanzapine is a short-acting antipsychotic useful in calming angry, aggressive patients regardless of diagnosis. The other drugs listed require long-term use to reduce anger. Lithium is for bipolar patients. Trazodone is commonly prescribed for patients experiencing depression, insomnia, or chronic pain. Valproic acid is for bipolar or borderline patients.

•CHAPTER 27 QUESTIONS •Question 1— Which clinical scenario predicts the highest risk for directing violent behavior toward others? • •A- Major depressive disorder with delusions of worthlessness •B- Obsessive-compulsive disorder; performs many rituals •C- Paranoid delusions of being followed by alien monsters •D- Completed alcohol withdrawal; beginning a rehabilitation program • •CHAPTER 27 QUESTIONS •Question 2— An intramuscular dose of antipsychotic medication needs to be administered to a patient who is becoming increasingly more aggressive and refused to leave the day room. The nurse should enter the day room... • •A- and say, "Would you like to come to your room and take some medication your health care provider prescribed for you?" •B- accompanied by three staff members and say, "Please come to your room so I can give you some medication that will help you regain control." •C- and place the patient in a basket-hold and then say, "I am going to take you to your room to give you an injection of medication to calm you." •D-accompanied by a male security guard and tell the patient, "Come to your room willingly so I can give you this medication, or the guard and I will take you there." • •CHAPTER 27 QUESTIONS •Question 3— Which assessment finding presents the greatest risk for violent behavior directed at others? • •A- Severe agoraphobia •B- History of spousal abuse •C- Bizarre somatic delusions •D- Verbalized hopelessness and powerlessness • •CHAPTER 27 QUESTIONS •Question 4— A patient sat in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stood, paced back and forth, clenched and unclenched fists, and then stopped and stared in the face of a staff member. The patient is... • •A- demonstrating withdrawal. •B- working though angry feelings. •C- attempting to use relaxation strategies. •D- exhibiting clues to potential aggression. • •CHAPTER 27 QUESTIONS •Question 5— Which medication from the medication administration record should a nurse administer to provide immediate intervention for a psychotic patient whose aggressive behavior continues to escalate despite verbal intervention? • •A- Lithium •B- Trazodone •C- Olanzapine •D- Valproic acid • •

1Answer: B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family. 2Answer: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence. 3Answer: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive. 4Answer: C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage. 5Answer: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.

•CHAPTER 28 QUESTIONS •Question 1— What feelings are most commonly experienced by nurses working with abusive families? • •A- Outrage toward the victim and discouragement regarding the abuser •B- Helplessness regarding the victim and anger toward the abuser •C- Unconcern for the victim and dislike for the abuser •D- Vulnerability for self and empathy with the abuser • •CHAPTER 28 QUESTIONS •Question 2— Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? The child who has... • •A- complaints of abdominal pain. •B- repeated middle ear infections. •C- bruises on extremities. •D- diarrhea. • • •CHAPTER 28 QUESTIONS •Question 3— A patient tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? • •A- History of family violence •B- Loss of employment •C- Abuse of alcohol •D- Poverty • • •CHAPTER 28 QUESTIONS •Question 4— An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? • •A- Tension-building •B- Acute battering/explosion •C- Honeymoon •D- Stabilization • • •CHAPTER 28 QUESTIONS •Question 5— An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? • •A- Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision •B- Wandering related to confusion and disorientation as evidenced by sleepwalking and falls •C- Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering •D-Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

1Answer: D Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion. 2Answer: B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps. 3Answer: D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion. 4Answer: B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. "Why" questions represent probing, which is a nontherapeutic communication technique. The victim may or may not have friends who have had this experience, but it is important to talk about his feelings rather than theirs. 5Answer: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.

•CHAPTER 29 QUESTIONS •Question 1— The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. • •A- "Your plan is not adequate. You could still be raped or sexually assaulted." •B- "I am glad you have this excellent safety plan. Would others like to comment?" •C- "It's better to walk with someone or call security when you enter or leave a building." •D- "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that." • •CHAPTER 29 QUESTIONS •Question 2— An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? • •A- The patient's vital signs •B- Consent signed by the patient •C- Supervision and credentials of the examiner •D- Storage location of the patient's personal effects • • •CHAPTER 29 QUESTIONS •Question 3— A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. • •A- "Rape can happen anywhere." •B- "Blaming yourself increases your anxiety and discomfort." •C- "You are right. You should not have been alone on the street at night." •D- "You feel as though this would not have happened if you had not been alone." • •CHAPTER 29 QUESTIONS •Question 4— A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim? • •A- "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." •B- "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." •C- "Do you have any male friends who have also been victims of sexual assault?" •D- "Why do you think you became a victim of sexual assault?" • • •CHAPTER 29 QUESTIONS •Question 5— A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should... • •A- say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." •B- provide written information about physical and emotional reactions the person may experience. •C- explain the need and importance of infectious disease and pregnancy tests. •D- give verbal information about legal resources in the community. •

1Answer: D The correctional nurse recognizes that events occurring in the present reality are likely to be incorporated into a flashback, leading the inmate to become more frightened and desperate to escape. Even if no longer experiencing a flashback, persons will likely re-experience their original trauma if restrained, including the emotions experienced during that trauma, leading to increased fearfulness and resistance to the jail restraints. Restraints are not likely to calm the individual or reduce aggressiveness but instead increase the sense of helplessness and desperation. 2Answer: B It is important for the nurse to be mindful of characteristics of the incarcerated population and not react personally to the comments. The nurse is safe; therefore, it is unnecessary to respond to the comments. The nurse has an obligation to provide care, which includes medication administration. Exploring the thoughts of other inmates may precipitate further problems. Seclusion is a last resort. The offending inmate's comments do not justify use of seclusion. 3Answer: A Legal sanity refers to the individual's ability to know right from wrong with reference to the act charged, the capacity to know the nature and quality of the act charged, and the capacity to form the intent to commit the crime. It is determined for the specific time of the act. The distracters apply to other parts of a mental status assessment and do not assess the patient's state at the time of the alleged crime. 4Answer: C A fact witness testifies regarding first-hand experience only; that is, the facts the witness possesses because of personal experience with the situation under review. Forensic nurse examiners conduct court-ordered examinations and provide written reports and court testimony regarding the findings of the examinations, but they do not give direct patient care. Consultants are neutral experts who educate or advise the Court or its officers on technical matters such as standards of nursing care. An expert witness shares professional expertise about the defendant or elements of the crime and testifies on behalf of the prosecution or defendant. 5Answer: C When compared to the rates in the general population (11% of whom have a mental health problem, with approximately 55,000 individuals hospitalized at an inpatient psychiatric hospital on any given day), correctional facilities carry a disproportionate share of the burden for the provision of mental health services. Rates of chronic illness are higher among inmates than in the general population due to factors such as higher rates of poverty, lower educational status, higher rates of trauma, institutional living when incarcerated, reduced access to health care, poor health habits, and higher rates of high-risk behaviors such as IV drug abuse. Correctional settings provide adequate care of inmates, but it is rarely holistic or comprehensive.

•CHAPTER 33 QUESTIONS •Question 1— An inmate was diagnosed with posttraumatic stress disorder (PTSD) caused by severe sexual abuse. One day this inmate sees a person with characteristics similar to the perpetrator, has a flashback, and then attacks the person. Correctional officers place the inmate in restraint. The correctional nurse should anticipate that the inmate would react to restraint by... • •A- committing to counseling to reduce the incidence of flashbacks. •B- becoming less likely to assault others during future flashbacks. •C- gradually calming and returning from the flashback to reality. •D- becoming more frightened, agitated, and combative. • •CHAPTER 33 QUESTIONS •Question 2— A large group of inmates are in line up at the prison clinic window for medication administration. One inmate near the end of the line calls out to the nurse using slang terms about the nurse's sexuality. What is the nurse's best action? • •A- Call for a guard to place the offending inmate in seclusion. •B- Ignore the comment and continue medication administration. •C- Ask the other inmates, "What do you think about those comments?" •D- Postpone the current medication administration until later in the day. • •CHAPTER 33 QUESTIONS •Question 3— Select the best question for a psychiatric forensic nurse examiner to ask when assessing the legal sanity of an individual charged with a crime. • •A- "Tell me about what you were thinking at the time of the alleged crime." •B- "What would you do if you heard a fire alarm going off where you live?" •C- "At this time, are you having any experiences that others might think strange?" •D- "Do you feel as though you would like to harm yourself or anyone else at the present time?" • • •CHAPTER 33 QUESTIONS •Question 4— A nurse testifies about care provided to a patient in the 8 hours before a successful suicide. The nurse responds to questions about observations regarding the patient's behavior as well as interventions performed and documented during the shift. In what capacity was this nurse testifying? • •A- Forensic nurse examiner •B- Expert witness •C- Fact witness •D- Consultant • • •CHAPTER 33 QUESTIONS •Question 5— Which statement about the practice of correctional nursing is accurate? • •A- Because the majority of inmates are younger than 40 years of age, most have lower rates of chronic illnesses than the general population. •B- Correctional nurses work primarily with medically ill persons rather than persons with psychiatric or substance abuse disorders. •C- More persons diagnosed with mental illness receive treatment services in prisons than in inpatient psychiatric facilities. •D- Correctional nurses commonly provide holistic and comprehensive care for the incarcerated population. • •

AVOID:

•Conducting a screen with others around •Talking outside the healthcare team •Judging or blaming the individual •Showing your feelings •Forcing responses •Forcing a physical exam

•Tertiary Prevention: lessens the impact of long-term sequelae

•Crisis centers with economic, child, long-term housing programs •Intervention groups to treat offenders

ASD Outcomes

•Early: recognition, referral, diagnosis, and intervention •Improved communication

Intermittent Explosive Disorder

•Pattern of alternating aggression and remorse due to environmental stimuli •Stage 1: stimuli triggers tension and arousal •Stage 2: explosive behavior and aggression •Stage 3: experience of sense of relief and release •Stage 4: feelings of remorse, regret, and guilt •Aggression towards self, other individuals, animals, property •Social, occupational, financial, legal consequences

Oppositional Defiant Disorder (ODD)***

•Pattern of the following behaviors for at least 6 months: •Angry and/or irritable mood •Argumentative and/or defiant behavior •Vindictiveness- spiteful and malicious behavior •Deliberately bothers and blames others for mistakes: •Mild: behaviors confined to one setting •Moderate: behaviors present in two settings •Severe: behaviors present in three or more settings •May lead to: lifelong difficulties with authority figures, functional performance

SEXUALITY

•Phases of the sexual response cycle •Phase 1: Desire •Phase 2: Excitement •Phase 3: Orgasm •Phase 4: Resolution

•Characteristics of Vulnerable Persons: Older Adults

•Poor mental or physical health -> Alzheimer's •Dependent on perpetrator • Female, older than 75 years, white, living with a relative •Elderly father cared for by a daughter he abused as a child Elderly woman cared for by a husband who has abused her in the past *CYCLE WHERE THE ABUSED BECOME THE ABUSERS

Timeout

•Purpose: allows for a break in the behaviors, time to think about why they are performing the behavior, self-control •Less restrictive than the quiet room or seclusion •Loses effectiveness when used too often

ASD Interventions *SOME INDIVIDUALS GENUINELY BELIEVE THAT VACCINES CAUSE AUTISM

•Set realistic goals for individual •Role model appropriate verbal communication, social skills •Role-playing (conflict and conflict resolution) •Allow time for transitions, give notice ahead of the change •Early interventions programs •Therapeutic nursery schools, day treatment programs, special education classes •Behavior management •Reward systems, establish expectations, consistency and follow- through with rules •Therapy: physical, occupational, speech •Pharmacological: goal to reduce anxiety, compulsive behaviors, agitation •SSRIs (gold standard for treatment)- increases level of mood and tolerance •Second-generation (atypical) antipsychotics- decrease destructive behaviors

SEXUAL ORIENTATION

•Sexual orientation is how a person characterizes their physical and emotional attraction to others. It has 3 dimensions: --->

RE-FEEDING SYNDROME

•Slow increase in calories •Monitor for peripheral edema, electrolytes, heart & resp. Rate

PTSD Interventions for Adults

•Stage One (Emergency) •Heightened state of emotions and behaviors •Stage Two (Numbing) •Attempt to protect the self to reduce anxiety •Avoidance, denial •Stage Three (Intrusive/Repetitive) •Nightmares, flashbacks •Possible confrontation of behaviors •Stage Four (Transition) •Acceptance, healing begins to occur •Stage Five (Integration) •Integration of newly learned skills, psychoeducation •Medication management- SSRIs, SNRIs, beta-blockers •Adjunctive therapies- group therapy, trauma-focused psychotherapy, relaxation techniques, hypnosis

What is somatization? psychological concerns are converted into physical symptoms.*

•Symptoms may be expressed in place of anxiety, depression, or irritability and cause functional impairment in daily living •Individuals can become ill from a stressor *Stress, depression, cancer, CV effects, & cultural considerations affect the medical conditions

The "Identified Patient"

•The "Identified Patient" is an individual in the family typically regarded by family members as "the problem." •Other family members believe the identified patient has beliefs, perceptions, actions, and responses that demand an immediate fix. •Sometimes the identified patient is actually the healthiest person in the family. Dysfunctional families may "scapegoat" a family member who is blamed for problems.

Resilience- overcome serious hardship

•The resilient child has the following characteristics: •Adaptability to changes in the environment •Ability to form nurturing relationships with other adults when the parent is not available •Ability to distance self from emotional chaos •Good social intelligence •Good problem-solving skills •Ability to perceive a long-term future

•Characteristics of Vulnerable Persons: Children

•Younger than 3 years •Perceived as different •Remind parents of someone they do not like •Product of an unwanted pregnancy Interference with emotional bonding between parent and child

Economic abuse:

•e.g., misusing, taking &/or withholding food, clothing, money, health care, possessions, property