Mental health exam 3 quiz questions

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient: a. expresses frustration verbally instead of physically. b. explains the rationale for behaviors to the victim. c. identifies three personal strengths. d. agrees to seek counseling.

A

A patient tells the nurse, "My husband is abusive most often 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

A

14. Which nursing intervention has the highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

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

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the norm.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for 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

B

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

B

Which statement reflects a truth about rape? A. Some women want to be raped. B. Rapists are oversexed. C. Most rapes are planned. D. Most women are raped by strangers.

C. Most rapes are planned. Many myths about rape exist. Most rapes are not impulsive, spur-of-the-moment acts, but are carefully planned and orchestrated.

A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance? Hypernatremia Hypokalemia Hypercalcemia Hypolipidemia

Hypokalemia

A client, who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds, eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data? Death anxiety Ineffective denial Disturbed sensory perception Imbalanced nutrition: less than body requirements

Imbalanced nutrition: less than body requirements

If it is determined that Mikayla has been sexually abused, what is the priority outcome for Mikayla? a. Mikayla's mother will learn coping techniques to support Mikayla. b. Mikayla will be able to verbalize exactly what happened to her. c. Mikayla will no longer act out sexually. d. The sexual abuse will cease.

d. The sexual abuse will cease. The highest priority in this case is that the abuse stops so that the patient can be safe and undergo recovery. The question is asked about the priority outcome for the victim, not the mother. Verbalizing exactly what happened is not a priority. The victim will most likely stop the sexualized behavior when the abuse has stopped and recovery is supported by age appropriate interventions.

An elderly client pays the bills because she fears that her family will make her live elsewhere if she doesn't "help out." The nurse assesses it as a. neglect. b. physical violence. c. psychological abuse. d. financial maltreatment.

d. financial maltreatment. Financial maltreatment occurs when the perpetrator takes financial advantage of the elderly person, often through the use of subtle threats of what unpleasant or frightening outcome will occur if the elder does not supply funds.

Anhedonia

refers to a loss of joy in life

Aphasia

refers to the loss of language ability.

Apraxia

refers to the loss of purposeful movement.

A client referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the client which question? "Do you often feel fat?" "Who plans the family meals?" "What do you eat in a typical day?" "What do you think about your present weight?"

"What do you eat in a typical day?"

A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. name two community resources that can be contacted. b. limit contact with the abuser by obtaining a restraining order. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

A

3. A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

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

A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Phobia of crowded places b. Risk of domestic abuse c. Migraine headaches d. Major depression

B

Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image? Denial Humor Altruism Projection

Denial

Which factor is of least importance as a victim of spousal abuse constructs an escape plan? a. How the victim will explain her decision to leave b. Where the victim will go to be safe c. How the victim will arrange for transportation d. What the victim will need to take with her when she leaves

a. How the victim will explain her decision to leave Any abused person has been threatened. This is a given and does not enter into the details of the escape planning.

Which of the following persons has the highest risk factors for physical abuse? a. Emma, a 7-month-old baby who has colic and doesn't sleep through the night b. Roland, a 53-year-old man with cardiovascular disease living with his son c. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder d. Rose, a 77-year-old woman living with her daughter and son-in-law

d. Rose, a 77-year-old woman living with her daughter and son-in-law Older women dependent on family members for care are at higher risk for abuse. The other options do not describe specific characteristics that put them at higher risk for abuse.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

A

An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "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 impairment, and lack of caregiver supervision b. Noncompliance, related to confusion and disorientation as evidenced by lack of cooperation c. Impaired verbal communication, related to brain impairment as evidenced by the confusion d. Insomnia, related to cognitive impairment as evidenced by wandering at night

A

An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

A

Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks

A

Which of the following are myths surrounding rape? (select all that apply): A. Women are usually raped by a stranger. B. Women do not "ask" to be raped by their behavior or dress. C. Most rapes occur away from home areas such as alleys and behind buildings. D. Documented rape cases include women from 8 to 70 years old. E. Rape is an expression of aggression and anger. F. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. G. Unless the assailant is armed, most women should be able to get away and avoid the rape.

A, C, D, F, G. These are all myths regarding rape. The other options are true.

During the immediate post-rape period what verbal nursing intervention would best lower client anxiety and increase feelings of safety? A. "You are safe here. I will stay with you while you have your examination." B. "I know you feel confused. We will make all the necessary decisions for you." C. "Please tell me as much about the details of the rape as you can remember." D. "When you leave you will be given follow-up appointments for pregnancy and sexually transmitted disease screening."

A. "You are safe here. I will stay with you while you have your examination." The presence of the nurse is reassuring, especially when the client is experiencing disorganization and the environment is confusing.

What reaction is most commonly displayed by rape victims in the immediate aftermath of the rape? A. Disorganization B. Philosophical acceptance C. Total withdrawal from reality D. Display of seductive actions

A. Disorganization The acute phase of rape trauma syndrome occurs immediately after the assault and may last for a few weeks. This stage is seen by emergency department personnel. Nurses are the ones most involved in dealing with these initial reactions. During this phase, a great deal of disorganization is common in the person's lifestyle and somatic symptoms.

Which statistic concerning rape is true? A. Most male rape victims do not report the crime. B. Male rape is perpetrated by homosexual men. C. The peak incidence of rape occurs in the 25 to 29 age group. D. Most rapes occur after abductions.

A. Most male rape victims do not report the crime. Option A is the only true statement.

Rape is best described as A. an act of violence using sex as the weapon. B. assault by a stranger on an unsuspecting victim. C. sexual desire satisfied inappropriately. D. an act prompted by early childhood neglect.

A. an act of violence using sex as the weapon. Rape is a violent crime. Sex is only the medium for perpetrating the crime.

The emergency department nurse planning care for a rape victim must realize that the emotional reaction displayed by many rape victims during the initial assessment and treatment is A. fear. B. eagerness. C. suspicion. D. disinterest.

A. fear. Rape is an act of violence, and sex is the weapon used by the perpetrator. Rape engulfs its victims in fear and anxiety, resulting in withdrawal for some and causing severe panic reactions in others. After being traumatized, the person who has been raped often carries an additional burden of shame, guilt, fear, anger, distrust, and embarrassment.

Which statement would be an appropriate long-term outcome for a rape client? The client will A. integrate the rape event and resume an optimal level of functioning. B. identify and develop coping skills necessary to reduce level of anxiety. C. blame the rapist rather than blame herself for the situation. D. repress feelings of shame, embarrassment, and self-blame.

A. integrate the rape event and resume an optimal level of functioning. This is the ideal long-term result of treatment for rape trauma syndrome, that life will go on and the client will return to the usual pre-trauma level of functioning.

Care planning for the rape victim is facilitated if the nurse understands that rape trauma syndrome is actually a variant of A. posttraumatic stress disorder. B. a maturational crisis. C. a dissociative disorder. D. generalized anxiety disorder.

A. posttraumatic stress disorder. Most of those who have been raped are eventually able to resume their previous lives after supportive services and crisis counseling. However, many carry with them a constant emotional trauma: flashbacks, nightmares, fear, phobias, and other symptoms associated with posttraumatic stress disorder.

To provide discharge treatment and support, the nurse should realize that the most common sequela(e) of acquaintance rape is the development of A. symptoms of sexual distress. B. anxiety and fear of men. C. a paranoid psychosis. D. an eating disorder.

A. symptoms of sexual distress. Women who have been raped by acquaintances frequently develop symptoms that prevent them from participating in normal sexual relations. Sexual distress is more common among women who have been sexually assaulted by intimates; fear and anxiety are more common in those assaulted by strangers. Depression occurs in both groups.

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply. a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to provide support d. Safety plan for the wife and children e. Placement of the children in foster care

ABC

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply. a. "Tell me how you punish your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever beat the children?" e. "Calling children 'stupid' injures their self-esteem."

ABC

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply. a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the telephone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Determine a code word to signal children that it is time to leave. g. Assemble birth certificates, Social Security cards, and licenses.

ACEFG

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

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

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

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

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

ANS: A Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI therapy and depression.

An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

ANS: A Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The patient takes lorazepam on a PRN basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the patient's drug regime, but interactions are more likely the problem.

An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

ANS: A Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

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

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

23. Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."

ANS: A Patients with eating disorders have distorted body images; they see themselves as overweight even when their weight is subnormal. "I'm thin for my height" is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as "I have nice eyes." Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: 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: 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: 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: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

ANS: 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.

20. Physical assessment of a patient with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

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

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

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

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

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

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

What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

ANS: A The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patient's sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.

4. A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell others perceptions of self. The patient with anorexia will persist in trying to lose more weight.

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

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

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

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

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

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

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

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

ANS: B A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

8. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

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

Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

ANS: B All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes.

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

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

During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

ANS: B Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patient's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

12. What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

ANS: B Memory impairment begins at stage 2 and progresses in stage 3. This patient is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

11. An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

ANS: B One goal of health teaching is the 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 concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

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

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

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

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

Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

ANS: B The listed health problems are all forms of dementia.

7. Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

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

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

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

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

A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d.Inability to feed or bathe self

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

16. While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing the symptoms of hypokalemia. d. self-esteem maintenance.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic 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 risk for hypokalemia.

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

ANS: C In the moderately severe stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the stage of severe cognitive decline, personality changes may take place, and the patient needs extensive help with daily activities. This patient has symptoms, so the preclinical stage does not apply.

Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

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

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

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

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

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

17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

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

A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

ANS: C The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.

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

ANS: C, D, E Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient's eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

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

ANS: C, D, E The correct answers are consistent with problems frequently identified for patients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The patient's cognition is too impaired to grieve.

26. When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

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

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

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

2. Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

ANS: 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 consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. Maintaining patients' concentration and attention. b. Shifting the patients' focus from food to psychotherapy. c. Focusing on weight control mechanisms and food preparation. d. Processing the heightened anxiety levels associated with eating.

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

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

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

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. Weigh self accurately using balanced scales. b. Limit exercise to less than 2 hours daily. c. Select clothing that fits properly. d. Gain 1 to 2 pounds.

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

9. A nursing care plan for a patient 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. Central nervous d. Cardiovascular

ANS: D Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

22. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

10. A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

ANS: D The correct response is the only strategy that attempts to question the patient's distorted thinking.

13. A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

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

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

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

5. A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 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

ANS: D The patient's history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.

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

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

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

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

Over the past year, a client has cooked gourmet meals for the family but eats only tiny servings. This person wears layered loose clothing and currently weighs 95 pounds, after a loss of 35 pounds. Which medical diagnosis is most likely? Binge eating Bulimia nervosa Anorexia nervosa Eating disorder not otherwise specified

Anorexia nervosa

A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient fill out an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.

B

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

B

After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies? a. Social isolation, related to lack of community support system b. Risk for injury, related to partner's physical abuse when intoxicated c. Deficient knowledge, related to resources for escape from the abusive relationship d. Disabled family coping, related to uneven distribution of power within a relationship

B

An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

B

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

B

Three weeks after a client was raped she tells the nurse, "I am going crazy. I have nightmares and wake up screaming. Then during the day all sorts of thoughts about the rape intrude into whatever I am concentrating on. I can't get anything done at work." The nurse should reply A. "Becoming mentally ill is a frightening thought for you?" B. "These are a normal response to stress and will decrease with time and therapy." C. "You are right to be concerned. I can give you a referral for treatment." D. "Would it help if you took some time off from work and stayed home?"

B. "These are a normal response to stress and will decrease with time and therapy." These symptoms are part of the response to rape trauma and parallel symptoms experienced by other victims of post-traumatic stress disorder.

When a client tells the nurse she was raped by her date several weeks ago, the most likely reason for taking so long to report the incidence is her A. embarrassment about having a physical examination. B. feelings of guilt for somehow having caused it. C. initial fear that no one would believe her. D. worry over contracting a sexually transmitted disease.

B. feelings of guilt for somehow having caused it. Many rape victims feel that they are somehow at fault for the rape and harbor feelings of guilt. This guilt stands in the way of reporting the rape to the authorities.

A sexual assault victim asks to be given "the morning-after pill" to prevent conception. The nurse does not believe in abortion. The action the nurse should take is to A. refer the woman for social services counseling. B. report and document the request. C. ask the supervising nurse to reassign the client. D. ask the client to reevaluate her request after 24 hours.

B. report and document the request. The nurse's ethical beliefs should never interfere with client rights. The nurse should report and document the client's request. If the drug is ordered, however, the nurse can request that another nurse administer the drug.

The nurse is meeting with a woman who was raped the previous week. The nurse's client education plan includes talking about the possibility of experiencing intrusive thoughts, increased motor activity, and fears and phobias in the next few weeks. The reason for this intervention is A. to help the client redevelop a sense of control over herself. B. that anticipatory guidance allows planning to decrease stress. C. that talking about feelings reduces their intensity. D. that self-destructive behaviors develop out of negative feelings.

B. that anticipatory guidance allows planning to decrease stress. Anticipatory guidance helps the client understand what to expect. When the expected occurs it is not as great a shock. Knowing what to expect also allows the client to plan for ways to cope.

Nicole is a 28-year-old married patient who comes to the emergency department after being raped on her way home from work. You have been with her as she cries and talks about what happened. She asks you, "What if I am pregnant?" Your response is guided by the knowledge that: A. the risk of pregnancy after rape is high, up to 50%. B. the risk of pregnancy after rape is high, up to 50%. C. reproductive functions shut down during a violent attack, and as a result pregnancy does not occur. D. Nicole may be worried about how her spouse will accept the baby.

B. the risk of pregnancy after rape is high, up to 50%. About 5% of women who are raped become pregnant as a result (Rape, Abuse & Incest National Network, 2008). Pregnancy prophylaxis can be offered in the emergency department after the results of the pregnancy test are available. The risk of pregnancy is not high after rape. Reproductive functions do not shut down during a violent attack. The patient may be worried about her spouse's reaction; however at this time most important consideration is to give the patient pertinent education regarding rape and pregnancy.

A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"

C

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

C

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

C

An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

C

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections b. severe colic c. bite marks d. croup

C

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. Support group b. Law enforcement c. Women's shelter d. Vocational counseling

C

It has been 6 months since Nicole was raped, and she has undergone counseling. Which statement by Nicole would indicate that an important outcome has been met? A. "I keep having nightmares about the rape and I can't sleep at night." B. "My husband has been very supportive during this whole thing." C. "I am not going to let that rapist be in control of my life. I know things will keep getting better." D. "I am not pressing charges because I want this whole thing to be over with so I can move on."

C. "I am not going to let that rapist be in control of my life. I know things will keep getting better." This option expresses empowerment and hope for the future. Long-term outcome includes the absence of any residual symptoms after the trauma and would be indicated by healing of physical injuries, relief of anger in nondestructive ways, comfort in relationships, and feelings of empowerment and expression of hope. Having nightmares and not sleeping indicates that the patient is still going through acute stress related to the rape. The fact that the husband is supportive is a positive statement regarding her husband but doesn't express her own indicators of recovery. Not pressing charges may indicate that the patient may not be dealing with the event in a healthy way by avoiding the trauma.

When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? A. "It makes sense that rape is a crime of violence, not a crime of sex." B. "Who would have guessed that most rape victims know the rapist?" C. "So if you dress conservatively, your risk of being raped is small." D. "I always thought rapes happened at night, but now I know that isn't true."

C. "So if you dress conservatively, your risk of being raped is small." Rapes have little to do with whether the victim dresses seductively because rape is a crime of violence rather than a crime of sex.

Nicole alternates between sobbing and being quiet and withdrawn. Which of the following illustrates best practice in giving care to a patient who has just been sexually assaulted? A. Sympathetic: "I'm so sorry for what you have been through." B. Reassuring: "Don't worry. It's hard now, but everything will be alright." C. Supportive: "I am going to stay with you. We can talk as long as you want to." D. Assertive: "Let's talk about new coping skills you can use."

C. Supportive: "I am going to stay with you. We can talk as long as you want to." The most effective approach for counseling in the emergency department or crisis center is to provide nonjudgmental care and optimal emotional support. Sympathy is not a therapeutic response and does not focus on the patient. Telling the patient not to worry is false reassurance. It is too soon to try to learn new coping skills because the patient is in an acute stress phase.

A rape victim in the emergency department keeps repeating, "I don't know why he did it." Although the nurse does not necessarily give the answer at this juncture, the nurse correctly identifies the motivation for most perpetrators of rape as A. anxiety relief. B. an overwhelming sexual desire. C. a desire to dominate and humiliate. D. a wish to be apprehended and punished.

C. a desire to dominate and humiliate. Power and domination, as well as humiliation of the victim, are the motivations for rape. In this scenario the nurse understands that rape is not a sexual act. Rape is a violent expression of aggression, anger, and the need for power.

A client who comes to the emergency department states she has just been raped. She displays a blank face and a rather calm appearance. During the assessment interview she seems unable to believe the event really happened. The nurse can assess this behavior as the client demonstrating a(an) A. defense mechanism that involves lying about the rape. B. behavioral reaction to the rape. C. emotional affective response to the rape. D. somatic reaction to stress from the rape.

C. emotional affective response to the rape. Emotional/Affective responses to rape can include fear of separation, abandonment, and for personal safety; anger or outrage; helplessness, hopelessness, or powerlessness; sadness or grief; denial, disbelief, or numbness; and guilt and distrust.

The nurse responding to the hotline call of a rape victim advises her to go to the nearest emergency department for treatment. When the woman states, "I'll think it over while I take a shower," the nurse A. questions her regarding the circumstances of the rape. B. advises her not to take too long before seeking treatment. C. explains that doing so could destroy evidence. D. asks if she may call a police woman to accompany her to the hospital.

C. explains that doing so could destroy evidence. Showering, washing, and changing clothes will destroy evidence such as semen and hairs shed from the perpetrator's body. Victims should be advised regarding what to do to preserve evidence.

In the acute phase of rape trauma syndrome, nursing interventions should focus on A. teaching stress management techniques to the client. B. helping the client's family clarify feelings. C. providing client support and safety. D. ensuring case management.

C. providing client support and safety. Helping the client feel safe and giving emotional support are two important interventions to combat the disorganization common during the acute phase of rape trauma syndrome.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

D

An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark glasses. Facial and body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

D

It has now been 1 year since Nicole's rape. Which of the following statements by Nicole would indicate that she has recovered from the trauma? A. "I don't walk home anymore because I am terrified it may happen again." B. "I am sleeping better but still only get about 5 hours of sleep at night because of bad dreams about the rape." C. "I realize that I was partly to blame for the rape because of walking in an unsafe neighborhood." D. "My husband and I are having sex again and I enjoy it.

D. "My husband and I are having sex again and I enjoy it. Sexual assault survivors are considered to be recovered if they are relatively free of any signs or symptoms of acute stress disorder and posttraumatic stress disorder. Signs of recovery include sleeping well with few instances of nightmares or dreams, being only mildly fearful, positive self-regard, and returning to prerape sexual functioning and interest. The closer the survivor's lifestyle is to how it was before the rape, the more complete the recovery has been. Not walking home because of being terrified indicates a high level of fear. Only sleeping 5 hours at night indicates sleeping is still seriously disturbed. Stating that she is partly to blame indicates that the patient is placing the blame for the rape on herself instead of the perpetrator.

A sexual assault victim tells the nurse, "I should have tried to fight him off! But I was so terrified that I could not move. I should have tried harder." A supportive response for the nurse to make would be A. "Try not to think about it. Put it out of your mind." B. "We each behave in characteristic ways in a crisis. That was your way." C. "Do you think others will think badly of you for not trying to fight?" D. "The way you behaved was the right thing to do at the time."

D. "The way you behaved was the right thing to do at the time." The victim should always be told that staying alive was the priority and that whatever she did to that end was the right thing to do.

Anticipatory teaching of a rape victim should include information that a common survivor problem that often develops during the long-term reorganization phase of rape trauma syndrome is A. denial of the event. B. headaches and fatigue. C. shock and numbness. D. intrusive thoughts.

D. intrusive thoughts. Just as in posttraumatic stress disorder, intrusive thoughts haunt the rape victim in the weeks and months during which long-term reorganization is occurring. Knowing that this is a common occurrence is reassuring to the client, who often is frightened by the symptom.

A client diagnosed with bulimia nervosa uses enemas and laxatives to purge to maintain weight. What is the likely physiological outcome of this practice? Increase in the red blood cell count Disruption of the fluid and electrolyte balance Elevated serum potassium level Elevated serum sodium level

Disruption of the fluid and electrolyte balance

Which subjective symptom should the nurse expect to note during assessment of a client diagnosed with anorexia nervosa? Lanugo Hypotension 25-lb weight loss Fear of gaining weight

Fear of gaining weight

The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic? Maintaining a normal weight Holding a distorted body image Doing more rigorous exercising Purging to keep weight down

Maintaining a normal weight

Which nursing intervention has the highest priority as a client diagnosed with anorexia nervosa begins to gain weight? Assess for depression and anxiety. Observe for adverse effects of refeeding. Communicate empathy for the client's feelings. Help the client balance energy expenditures with caloric intake.

Observe for adverse effects of refeeding.

Which statement is true of the eating disorder referred to as bulimia? Patients with bulimia often appear at a normal weight. Patients with bulimia binge eat but do not engage in compensatory measures. Patients with bulimia severely restrict their food intake. One sign of bulimia is lanugo.

Patients with bulimia often appear at a normal weight.

Which statement made by a parent of a child diagnosed with Tourette's syndrome would be assessed as a risk factor for family violence? a. "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs." b. "Our son is really a good little boy, but he needs to be disciplined both at home and in school." c. "We shouldn't be, but we are ashamed of our son's disorder and his inability to control the tics in public." d. "We have become active in the support group but still find the suggestions extremely difficult to put into practice."

a. "My husband lost his job, and it seems all our savings are going to pay for our son's expensive medication and all the other things he needs." Job loss, financial problems, and a child who is "different" and has special needs should alert the nurse to the risk for family violence, because all these factors contribute to a crisis situation.

A battered woman has been referred to a women's shelter. When the woman's abuser demands to be told where she is, the nurse a. refuses to provide any information. b. gives him the telephone number, but not the address, of the shelter. c. informs him that no information can be given for a minimum of 24 hours. d. calls law enforcement to arrest the husband for the assault and battery of his wife.

a. refuses to provide any information. The nurse must respect the client's right to confidentiality. Whether the questioner asks pleadingly or in a demanding way, the answer must be the same.

The risk of elder abuse in a home is best determined by assessing a. the vulnerability of the elder and the stress of the caregiver. b. the amount of disruption the elder causes in the home. c. how much actual physical assistance the elder needs on a daily basis. d. the financial contribution of the elder and the caregiver's early life experience with abuse.

a. the vulnerability of the elder and the stress of the caregiver. Abuse occurs across all segments of society and is reinforced by the society and the culture. The actual occurrence of violence requires (1) a perpetrator, (2) someone who by age or situation is vulnerable (e.g., children, women, men, the elderly, mentally ill persons, and physically challenged persons), and (3) a crisis situation.

Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present: a. with vague physical complaints such as insomnia or pain. b. with extreme anger and unpredictable behavior. c. with many family members there to support them. d. with psychosis and/or mania as a result of long-term abuse.

a. with vague physical complaints such as insomnia or pain. Patients may present with symptoms that may be vague and can include chronic pain, insomnia, hyperventilation, or gynecological problems. Attention to the interview process and setting is important to facilitate accurate assessment of physical and behavioral indicators of family violence. Presenting with extreme anger is possible but not as common as presenting with vague physical complaints. Having many family members there is unlikely as many victims keep their history of being battered a secret. It is not known that psychosis or mania is a result of physical violence, and this would not be a usual presenting complaint.

Lauren brings her 4-year-old daughter, Mikayla, to the emergency department and states that Mikayla has been "acting funny." Lauren states, "She touches her vagina and rubs herself down there all the time and she never did that before. She drew me a picture showing two people with one on top of the other and said they were 'doing sex' and I saw her acting that out with her dolls too. I didn't know where else to go." Based on Lauren's description, you suspect that: a. this is normal developmental behavior in a 4-year-old child. b. Mikayla has been sexually abused. c. Lauren needs education in parenting skills. d. Mikayla has been exposed to graphic sexual images on television.

b. Mikayla has been sexually abused. Sexualized behavior is one of the most common symptoms of sexual abuse in children. Younger children may draw sexually explicit images, demonstrate sexual aggression, or act out sexual interactions in play, for example, with dolls. Masturbation may be excessive in sexually abused children. It is not normal developmental behavior for a 4-year-old child. The other options may be true, but sexual abuse is more likely and must be investigated.

A nursing intervention directed at the psychological needs of an abused woman is to a. encourage the client to immediately leave the abuser. b. affirm that the client did not deserve or cause the abuse. c. provide a referral to social services for economic problems. d. facilitate contact with law enforcement to take legal action.

b. affirm that the client did not deserve or cause the abuse. Abused clients often believe that they are deserving of the abuse and, in some way, prompt the abuser to attack. They need specific reassurance that they did not deserve to be abused and they did not cause the attack.

When the nurse believes the cycle of abuse is escalating and that a woman may be in severe physical danger, the priority nursing intervention is to a. advise her to enter counseling at the mental health center. b. assist her to develop a plan to go to a shelter in case of a crisis. c. suggest she leave the abuser and go to a trusted friend's home. d. teach her to counter verbal abuse with assertive replies.

b. assist her to develop a plan to go to a shelter in case of a crisis. Every victim of abuse should have an escape plan, but one is particularly important when the nurse believes the client is in severe danger.

To best assure the safety of a 3-year-old child whose parent admits to finding it difficult to control their anger, the most appropriate short-term goal would be for the parent to a. understand the impact of violence on the child within 2 days. b. begin attending anger management training sessions within 2 weeks. c. state a willingness to attend a support group for physical abusers within 1 week. d. show remorse for their anger management issues within 2 days.

b. begin attending anger management training sessions within 2 weeks. Perpetrators of violence need help learning how to manage anger. A structured group is an excellent way to provide this teaching.

An abuse victim tearfully tells the nurse in the emergency department, "Don't tell my husband that you know he beats me because if he thinks anyone knows, he will beat me again." Based on this information, the most appropriate nursing diagnosis is a. chronic pain. b. fear. c. post-trauma syndrome. d. risk for self-directed violence.

b. fear. The client is expressing fear based on a known threat.

When there is reason to suspect that a child is being abused, the nurse must initially a. call the local police to report it. b. follow agency policy for reporting. c. confront the parent or parents. d. interrogate the child to obtain proof.

b. follow agency policy for reporting. Nurses are mandated reporters of child abuse. They must follow the rules set forth by the state regarding the steps to take to report child abuse.

The nurse performing the assessment of a wheelchair-bound client suspects that his wife's explanation of how he sustained facial contusions and a broken nose may not be entirely truthful. The nurse should a. confront the wife with the suspicion that her husband's injuries are the result of abuse. b. have the wife wait in the waiting room so her husband can be interviewed in private. c. report the husband's injuries to the police and ask for a confidential investigation. d. document the suspicion and follow a policy of "wait and see" whether he returns again.

b. have the wife wait in the waiting room so her husband can be interviewed in private. Suspected victims of abuse should always be interviewed in private. If the perpetrator is in the room, the victim cannot speak freely.

When treatment for injuries sustained during an incident of abuse is sought from the primary physician, the client is receiving a. primary prevention. b. secondary prevention. c. tertiary prevention. d. stop-gap therapy.

b. secondary prevention. Secondary prevention is synonymous with treatment.

After arranging for a sexual assault nurse examiner (SANE) to see Lauren and Mikayla for further assessment for abuse and proper reporting and follow-up, Lauren tells you she lives with her boyfriend, Darrin, who is not Mikayla's father. What statement by Lauren would make you suspect she is being emotionally abused? a. "Darrin has a good job and keeps control of all the finances but our electricity still got turned off last week." b. "I didn't tell Darrin I was coming because he is under so much stress at work I didn't want to add to it." c. "Darrin yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." d. "Darrin is Latin American and has a fiery temper."

c. "Darrin yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." Emotional abuse may be less obvious and more difficult to assess than physical violence, but it can be identified through indicators such as low self-esteem, reported feelings of inadequacy, and anxiety. Controlling the finances and having the electricity turned off describes the possibility of economic abuse. Not wanting to add to the boyfriend's stress does not describe an abusive situation. The spouse being Latin American with a temper would more likely hint at physical abuse rather than emotional.

Which child is at lowest risk for abuse? a. A 3-month-old who has colic and teenaged parents. b. A 4-year-old who has cerebral palsy and retarded parents. c. A 2-year-old who has leukemia and two working parents. d. A 5-year-old who has ADHD and a father who was abused as a child.

c. A 2-year-old who has leukemia and two working parents. Although the child in option C has a serious physical disorder, she is at lower risk than the child in option A, whose inconsolable crying can be frustrating; the child in option B, who will not be as independent as other children his age and who has parents who may not understand his needs; or the child in option D, whose hyperactivity can be annoying, especially to a parent who himself has been abused.

Which of the following is a likely behavior for a woman attempting to escape a chronically abusive relationship? a. Relying on alcohol to escape the emotional pain of abuse b. Adapting an aggressive attitude toward her abuser to scare him c. Considering ways to commit suicide d. Threatening to call the police if she is abused again

c. Considering ways to commit suicide A person experiencing violence may feel so trapped in a detrimental relationship, yet so desperate to get out, that suicide may seem the only answer. A suicide attempt may be the presenting symptom in the emergency department. At least 10% of abused women attempt suicide. The other reports are not realistic for a woman who is being abused.

Which statement reflects a fact about family violence? a. Ninety-five percent of abuse victims are women. b. The victim's behavior is often the cause of the violence. c. Violence occurs in families of all backgrounds. d. Alcohol and stress are the major causes of abuse.

c. Violence occurs in families of all backgrounds. Option C is a true statement. The others are false.

When interviewing an adult victim of abuse, the nurse's best approach is to be a. confrontational and assertive. b. gentle and direct. c. direct and professional. d. sympathetic and outraged.

c. direct and professional. Expressing strong emotion does not help the victim. A direct, honest, and professional manner of asking questions produces the best results.

A 4-year-old child tells the nurse, "I'm a bad boy. Daddy always says I'm not worth a second look." This situation can be an example of a. neglect. b. physical maltreatment. c. emotional violence. d. harsh parenting.

c. emotional violence. Emotional violence occurs when the child's self-esteem is attacked. It is as devastating to the child as physical abuse.

An elderly woman who has been abused by her caregiver daughter tells the nurse, "You don't have to worry about me. My daughter cried and apologized. She promised me she will never hit me again." The nurse can assess that this is the stage in the cycle of violence known as a. tension building. b. acute battering. c. honeymoon. d. escalation.

c. honeymoon. During the honeymoon stage, the perpetrator apologizes, promises never to abuse again, and tries to make up for the violence. This stage is usually brief.

The victim of abuse can expect the abuse to worsen when a. the perpetrator feels he is in complete control. b. the perpetrator is feeling remorseful for being abusive. c. the victim moves toward independence from the abuser. d. the victim submits to the domination of the perpetrator.

c. the victim moves toward independence from the abuser. When the abuser thinks he is losing control over the victim, the violence escalates.

What distinction can be made between abuse and neglect? a. Neglect occurs in the psychological domain; abuse occurs in the physical domain. b. Neglect is always physical; abuse can be verbal, physical, sexual, or emotional. c. Neglect is perpetrated against children; abuse victims can be children or adults. d. Neglect is a failure to provide; abuse is a failure to control aggression.

d. Neglect is a failure to provide; abuse is a failure to control aggression. Neglect is failure to provide necessary care, and abuse is physical maltreatment.

Agnosia

refers to the loss of sensory ability to recognize objects.