Mental health final- chapters 12-14, 17, 18, 21-24, 27-29

A patient referred to the eating disorders clinic has lost 35 pounds during the past 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?"

"What do you eat in a typical day?"

A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the Court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent's behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. CD

CD

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response . a. "Are you thinking of harming yourself?" b. "It will take time, but you will feel the same as before the attack." c. "Your friends will understand when you explain it was not your fault." d. "You will be able to find meaning from this experience as time goes on."

a. "Are you thinking of harming yourself?"

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

a. "Converses with few interruptions; clothing matches; participates in activities."

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

a. "I am fat and ugly."

A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that you are not satisfied with the care you are receiving." c. "Let's talk about why you use your call light so frequently. It is a problem." d. "You frustrate the staff by calling them so often. Why are you doing that?"

a. "I'm wondering if you are feeling anxious about your illness and being left alone."

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

a. "Let's consider the advantages of being able to stop and think before acting."

Which comment by a patient who recently experienced a myocardial infarction indicates use of maladaptive, ineffective coping strategies? a. "My employer should have paid for a health club membership for me." b. "My family will see me through this. It won't be easy, but I will never be alone." c. "My heart attack was no fun, but it showed me up the importance of a good diet and more exercise." d. "I accept that I have heart disease. Now I need to decide if I will be able to continue my work daily."

a. "My employer should have paid for a health club membership for me."

A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion."

A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest 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 an interview with these parents? (Select all that apply.) a. "Tell me how you discipline 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 spank your children?" e. "Calling children 'stupid' injures their self-esteem."

a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult."

A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? (Select all that apply.) a. "The importance of taking your medication correctly" b. "How to complete an application for employment" c. "How to dress when attending community events" d. "How to give and receive compliments" e. "Ways to quit smoking"

a. "The importance of taking your medication correctly" e. "Ways to quit smoking"

Which assessment question could a nurse ask to help identify secondary gains associated with a somatic symptom disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"

a. "What are you unable to do now but were previously able to do?"

During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

a. "You are feeling violated because you thought you could trust your partner."

Which scenarios describe completed rape? (Select all that apply.) a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.

a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.

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

a. A list of all medications the person currently takes

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.) a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways. d. Invite the patient's family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.

a. Allow the patient to talk at a comfortable pace. b. Place the patient in a private room with a caregiver. c. Pose questions in nonjudgmental, empathetic ways.

Which central nervous system structures are most associated with anger and aggression? (Select all that apply.) a. Amygdala b. Cerebellum c. Basal ganglia d. Temporal lobe e. prefrontal cortex

a. Amygdala d. Temporal lobe e. prefrontal cortex

A nurse directs the intervention team who places an aggressive patient in seclusion. Before approaching the patient, which actions will the nurse direct team members to take? (Select all that apply.) a. Appoint a person to clear a path and open, close, or lock doors. b. Quickly approach the patient and take the closest extremity. c. Select the person who will communicate with the patient. d. Move behind the patient when the patient is not looking. e. Remove jewelry, glasses, and harmful items.

a. Appoint a person to clear a path and open, close, or lock doors. c. Select the person who will communicate with the patient. e. Remove jewelry, glasses, and harmful items.

Which nursing intervention has the highest priority for a patient diagnosed 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 needs for health teaching.

a. Assist the patient to identify triggers to binge eating.

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.

a. Assist the patient to perform simple tasks by giving step-by-step directions.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

a. Attending psychoeducation sessions

An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.) a. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer

a. Camera b. Body map c. DNA swabs

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." 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. Chronic low self-esteem related to negative feedback from parents

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms, the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

a. Coping mechanisms, the patient is using d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system

A patient admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

a. Denial

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams e. Syncopal episodes

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack."

An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam 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

a. Drug actions and interactions

Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

a. Empathetic, supportive

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

a. Euphoric

A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient's history support the suspected diagnosis? (Select all that apply.) a. Family history of mental illness b. Allergies to multiple antibiotics c. Long history of severe facial acne d. Father with history of alcohol abuse e. History of an abusive relationship with one parent

a. Family history of mental illness d. Father with history of alcohol abuse e. History of an abusive relationship with one parent

An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a. Family therapy b. Bibliotherapy c. Play therapy d. art therapy

a. Family therapy

A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment findings regarding this patient support the suspected diagnosis? (Select all that apply.) a. Female b. Reports frequent syncope c. Rates pain as "1" on a scale of "10" d. First diagnosed with psoriasis at age 12 e. Reports insomnia often results from back pain

a. Female b. Reports frequent syncope e. Reports insomnia often results from back pain

Which is an effective nursing intervention to assist an angry patient learn to manage anger without violence? a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking. b. Provide negative reinforcement such as restraint or seclusion in response to angry outbursts, whether or not violence is present. c. Use aversive conditioning, such as popping a rubber band on the wrist, to help extinguish angry feelings. d. Administer an antipsychotic or antianxiety medication.

a. Help a patient identify a thought that produces anger, evaluate the validity of the belief, and substitute reality-based thinking.

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

a. History of family violence

Which assessment findings suggest the possibility of a factitious disorder, imposed on self-type? (Select all that apply.) a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries c. Going from one doctor to another seeking the desired response d. Claims illness to obtain financial benefit or other incentive e. Difficulty describing symptoms

a. History of multiple hospitalizations without findings of physical illness b. History of multiple medical procedures or exploratory surgeries

A nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

a. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia

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

a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January b. April c. June d. September

a. January

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.) a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone 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. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

a. Keep a cell phone fully charged. c. Have the phone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave.

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/day.

a. Label the bathroom door.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.) a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Supervise medication administration. e. Monitor the patient's sleep patterns.

a. Limit credit card access. b. Provide a structured environment. d. Supervise medication administration. e. Monitor the patient's sleep patterns.

A patient diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

a. Make observations.

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

a. Monitor vital signs.

Which assessment findings support a diagnosis of ODD? a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. b. Exhibits involuntary facial twitching and blinking; makes barking sounds. c. Violates others' rights; cruelty toward people or animals; steals; truancy.

a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior.

For which patients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment.

Parents of an adolescent diagnosed with a CD say, "We don't know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?" Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy

a. Parent-child interaction therapy (PCIT)

A 10-year-old 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 as priorities 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 give support d. A safety plan for the wife and children e. Placing the children in foster care

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support

Because an intervention was required to control a patient's aggressive behavior, the nurse plans a critical incident debriefing with staff members. Which topics should be the primary focus of this discussion? (Select all that apply.) a. Patient behaviors associated with the incident b. Genetic factors associated with aggression c. Intervention techniques used by the staff d. Effects of environmental factors e. Theories of aggression

a. Patient behaviors associated with the incident c. Intervention techniques used by the staff d. Effects of environmental factors

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

a. Peripheral edema c. Constipation d. Hypotension f. Lanugo

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a. Powerlessness c. Chronic low self-esteem

The staff development coordinator plans to teach use of physical management techniques for use when patients become assaultive. Which topic should the coordinator emphasize? a. Practice and teamwork b. Spontaneity and surprise c. Caution and superior size d. Diversion and physical outlets

a. Practice and teamwork

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.

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

A patient diagnosed with moderate stage Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. (Select all that apply.) 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 antianxiety 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.

a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. e. If the patient resists dressing, use distraction and try again after a short interval.

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

a. Refer requests and questions related to care to the case manager.

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) a. Refer the nurse to a peer assistance program. b. Confront the nurse in the presence of a witness. c. Immediately terminate the nurse's employment. d. Relieve the nurse of responsibilities for patient care. e. Require the nurse to undergo immediate drug testing.

a. Refer the nurse to a peer assistance program. d. Relieve the nurse of responsibilities for patient care.

What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patient's need for periods of social isolation. b. Prevent the patient from violating the nurse's rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.

a. Respect the patient's need for periods of social isolation.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury

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

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

a. Risk for injury related to physical abuse from partner

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

a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision

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

a. Risk for other-directed violence

A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? (Select all that apply.) a. Risk for other-directed violence b. Disturbed thought processes c. Risk for loneliness d. Spiritual distress e. Social isolation

a. Risk for other-directed violence b. Disturbed thought processes

An adolescent diagnosed with CD has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication? a. Second-generation antipsychotic b. Antianxiety medication c. Calcium channel blocker d. β-blocker

a. Second-generation antipsychotic

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

a. Self-mutilation

Which features should be present in a therapeutic milieu for a patient experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

a. Simple and safe

Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Desensitization techniques d. Use of complementary therapy

a. Social skills training

A patient diagnosed with a somatic symptom disorder says, "Why has God chosen me to be sick all the time and unable to provide for my family? The burden on my family is worse than the pain I bear." Which nursing diagnoses apply to this patient? (Select all that apply.) a. Spiritual distress b. Decisional conflict c. Adult failure to thrive d. Impaired social interaction e. Ineffective role performance

a. Spiritual distress e. Ineffective role performance

A patient with a history of command hallucinations approaches the nurse yelling obscenities. Which nursing actions are most likely to be effective in deescalation for this scenario? (Select all that apply.) a. Stating the expectation that the patient will stay in control. b. Asking the patient, "Do you want to go into seclusion?" c. Telling the patient, "You are behaving inappropriately." d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

a. Stating the expectation that the patient will stay in control. d. Offering to provide the patient with medication to help. e. Speaking in a firm but calm voice.

Which behavior best demonstrates aggression? a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart. b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing. c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch." d. Telling the medication nurse, "I am not going to take that, or any other, medication you try to give me."

a. Stomping away from the nurses' station, going to the hallway, and grabbing a tray from the meal cart.

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine (IOM)-National Research Council c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

a. Substance Abuse and Mental Health Services Administration (SAMHSA)

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

a. Support the victim to separate issues of vulnerability from blame.

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome? a. The acute phase reaction b. The long-term phase c. A delayed reaction d. The angry stage

a. The acute phase reaction

A 16-year-old diagnosed with a conduct disorder (CD) has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.

a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.

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

a. The child frequently eats newspapers and magazines.

A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? a. The nurse interacts with the patient in a protective fashion. b. The nurse's comments to the patient are compassionate and nonjudgmental. 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.

a. The nurse interacts with the patient in a protective fashion

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

a. The patient's history of poly-substance abuse

When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

a. Tolerance has developed.

An older adult patient in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful? a. Use the patient's glasses. b. Place personally meaningful objects in view. c. Position large clocks and calendars on the wall. d. Assure that the room is brightly lit but very quiet at all times.

a. Use the patient's glasses.

A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a. Word salad b. Neologism c. Anhedonia d. Echolalia

a. Word salad

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 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.

a. assess lung sounds and extremities.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder. d. cyclothymic disorder.

a. bipolar I disorder.

A nurse's neighbor says, "I saw a news story about a man without any known illness who died suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be fatal?" The nurse should respond by noting that some serious medical conditions may be complicated by emotional stress, including (Select all that apply) a. cancer. b. hip fractures. c. hypertension. d. immune disorders. e. cardiovascular disease.

a. cancer. c. hypertension. d. immune disorders. e. cardiovascular disease

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as a. codependence. b. assertiveness. c. role reversal. d. homeostasis.

a. codependence.

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.

a. delirium.

A nurse works at rape telephone hotline. Communication with potential victims should focus on a. explaining immediate steps victims should take. b. providing callers with a sympathetic listener. c. obtaining information for law enforcement. d. arranging counseling.

a. explaining immediate steps victims should take.

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? The adult 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. expresses frustration verbally instead of physically.

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in adolescents who a. have been abused. b. are attention seeking. c. have eating disorders. d. are developmentally delayed.

a. have been abused.

A health teaching plan for a patient taking lithium should include instructions to a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet.

A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should a. make sure there is adequate physical space between the nurse and patient. b. move into a position that places the patient close to the door. c. maintain one arm's length distance from the patient. d. begin talking to the patient about appropriate behavior.

a. make sure there is adequate physical space between the nurse and patient.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

a. meals.

A patient is experiencing psychomotor agitation associated with major depressive disorder. Which observation would the nurse associate with this symptom? The patient a. paces aimlessly around the room. b. asks the nurse to repeat instructions. c. complains of prickly skin sensations. d. demonstrates slowed verbal responses.

a. paces aimlessly around the room.

Physical assessment of a patient diagnosed with bulimia often reveals a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.

a. prominent parotid glands.

The nurse can assist a patient to prevent substance abuse relapse by (Select all that apply) a. rehearsing techniques to handle anticipated stressful situations. b. advising the patient to accept residential treatment if relapse occurs. c. assisting the patient to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

a. rehearsing techniques to handle anticipated stressful situations. c. assisting the patient to identify life skills needed for effective coping. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

A hospitalized patient diagnosed with delirium misinterprets reality. 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.

a. remain safe in the environment.

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.

a. returning to premorbid levels of function.

The exact cause of bipolar disorder has not been determined; however, for most patients a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

a. several factors, including genetics, are implicated.

Select the priority outcome for a patient completing the fourth alcohol detoxification program in the past year. Prior to discharge, the patient will a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

a. state, "I know I need long-term treatment."

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

a. verbalize realistic positive characteristics about self by (date).

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

a. within therapeutic limits.

A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking? a. "The table of contents tells what a book is about." b. "You can't judge a book by looking at the cover." c. "Things are not always as they first appear." d. "Why are you asking me about books?"

a. "The table of contents tells what a book is about."

An acutely violent patient diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the prn medication administration record. b. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.

a. Administer diphenhydramine 50 mg IM from the prn medication administration record.

A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

a. An acute dystonic reaction

The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a. Psychoeducational

When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a. Sedation and muscle stiffness

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

a. a neologism.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

b. "A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder."

A patient diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

b. "An individual is supported by peers while striving for abstinence one day at a time."

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

b. "Has the victim consumed any alcohol?"

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depressive disorder. Which comment by the patient indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

b. "I might be a little dizzy or have a mild headache after each procedure."

A patient says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain, but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

b. "I understand that you have pain, but giving medicine too soon would not be safe."

A patient diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

b. "Let's look at one bad thing that happened to see if another explanation exists."

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."

b. "Let's see if there are any other possible explanations for your vomiting."

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?"

b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person."

An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention? a. "I hate all of you!" b. "My fingers are tingly." c. "You wait until I tell my lawyer." d. "The other patient started the fight."

b. "My fingers are tingly."

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Most patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

b. "Taking the medication every day helps reduce the risk of a relapse."

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."

b. "The confusion will probably get better as we treat the infection."

A patient diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

b. "You're wearing a new shirt."

During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

b. Affect flat; mood depressed

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

b. Alzheimer's disease

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

b. Alzheimer's disease

Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? a. Narcotic analgesics for use as needed for acute pain b. Antidepressant medications to treat co-morbid depression c. Long-term use of benzodiazepines to support coping with anxiety d. Conventional antipsychotic medications to correct cognitive distortions

b. Antidepressant medications to treat co-morbid depression

A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/minute 0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse's priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

b. Begin the detox protocol.

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. anxiety

b. Callous attitude d. Aggression

A patient with blindness related to conversion (functional neurological) disorder says, "All the doctors and nurses in the hospital stop by often to check on me. Too bad people outside the hospital don't find me as interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

b. Chronic low self-esteem

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

b. Confabulation

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias

b. Confusion and disbelief

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

b. Consent signed by the patient

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

b. Dementia

Which nursing diagnosis would most likely apply to a patient diagnosed with major depressive disorder as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern

A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? a. Planned ignoring b. Establish firm limits c. Neutrally permit refusals d. Coaxing to gain compliance

b. Establish firm limits

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.

b. Focus interaction on familiar topics

A patient has a history of impulsively acting-out anger by striking others. Select the most appropriate intervention for avoiding similar incidents. a. Teach the patient about herbal preparations that reduce anger. b. Help the patient identify incidents that trigger impulsive anger. c. Explain that restraint and seclusion will be used if violence occurs. d. Offer one-on-one supervision to help the patient maintain control.

b. Help the patient identify incidents that trigger impulsive anger.

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

b. Helplessness regarding the victim and anger toward the abuser

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

b. History of spousal abuse

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

b. Illness anxiety disorder (hypochondriasis)

A patient diagnosed as mild stage Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the 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

b. Impaired memory

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Impaired mood regulation c. Sleep deprivation

child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder imposed on another is suspected. Which nursing interventions are appropriate? (Select all that apply.) a. Increase private visiting time for the parents to improve bonding. b. Keep careful, detailed records of visitation and untoward events. c. Place mittens on the child to reduce access to ports and incisions. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.

b. Keep careful, detailed records of visitation and untoward events. d. Encourage family members to visit in groups of two or three. e. Interact with the patient frequently during visiting hours.

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

b. Maintaining consistent limits

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

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

b. Mood stabilizing medication

A new patient acts out so aggressively that seclusion is required before the admission assessment is completed or orders written. Immediately after safely secluding the patient, which action is the nurse's priority? a. Complete the physical assessment. b. Notify the health care provider to obtain a seclusion order. c. Document the incident objectively in the patient's medical record. d. Explain to the patient that seclusion will be discontinued when self-control is regained.

b. Notify the health care provider to obtain a seclusion order.

What are the primary distinguishing factors between the behavior of persons diagnosed with ODD and those with CD? The person diagnosed with (Select all that apply) a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from loved ones. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

b. ODD tests limits and disobeys authority figures. e. CD often violates the rights of others.

A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support a diagnosis of a. CD. b. ODD. c. intermittent explosive disorder. d. ADHD.

b. ODD.

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

b. Observe for adverse effects of refeeding.

A hospitalized patient diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

b. One-on-one supervision

A patient diagnosed 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 may be unreliable. b. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care. c. Because of increased risk of physical problems with refeeding, the patient's permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.

b. Patient involvement in decision making increases sense of control and promotes adherence to the plan of care.

Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a. Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains

b. Patient's style of presentation

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 for enhancing 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.

b. Place locks at the tops of doors.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

b. Provide a subdued environment.

A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic

b. Respiratory

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

b. Rigidity, perfectionism

A patient diagnosed with major depressive disorder repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide

an older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my 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 about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care.

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization

b. Self-blame

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

b. Set limits on patient behavior as necessary.

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

b. Strong negative feelings interfere with assessment and judgment.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

b. Supporting physiological stability

An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins shouting at the nurse. What is the nurse's initial action to defuse the situation? a. Say to the child, "Tell me how you're feeling right now." b. Take the child swimming at the facility's pool. c. Establish a behavioral contract with the child. d. Administer an anxiolytic medication.

b. Take the child swimming at the facility's pool.

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, "I'm in pain all the time but you don't give me medicine until YOU think it's time." Which nursing intervention would best address this problem? a. Teach the patient to use coping strategies such as deep breathing and progressive relaxation to reduce the pain. b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia. c. Tell the patient that verbal assaults on nurses will not shorten the wait for analgesic medication. d. Talk with the patient about the risks of dependency associated with overuse of analgesic medication.

b. Talk with the health care provider about changing the pain medication from prn to patient-controlled analgesia.

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.

b. The patient's anxiety is relieved through the physical symptom.

n the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. Select the priority outcome. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute.

A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because (Select all that apply) a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent. e. adolescents usually relate better to authority figures than peers.

b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. d. acceptance and trust convey feelings of security for the adolescent.

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."

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."

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

b. anhedonia.

A patient undergoing alcohol rehabilitation decides to begin disulfiram therapy. Patient teaching should include the need to (Select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

b. avoid alcohol-based skin products. c. read labels of all liquid medications. f. avoid breathing fumes of paints, stains, and stripping compounds.

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.

b. be resistant to accepting psychiatric help.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? It will a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

b. bring hyperactivity under rapid control.

Priority interventions for a patient diagnosed with major depressive disorder and feelings of worthlessness should include a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b. careful unobtrusive observation around the clock.

A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, the nurse's first intervention is to a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

b. clear the room of all other patients.

patient with a somatic symptom disorder has the nursing diagnosis Interrupted family processes related to patient's disabling symptoms as evidenced by spouse and children assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the patient will a. assume roles and functions of other family members. b. demonstrate performance of former roles and tasks. c. focus energy on problems occurring in the family. d. rely on family members to meet personal needs.

b. demonstrate performance of former roles and tasks.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

b. distorted thought self-control.

This nursing diagnosis applies to a patient experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day.

A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should a. establish a "buddy" system with other patients who can feed the patient at each meal. b. expect the patient to feed self after explaining arrangement of the food on the tray. c. direct the patient to locate items on the tray independently and feed self. d. address needs of other patients in the dining room, then feed this patient.

b. expect the patient to feed self after explaining arrangement of the food on the tray.

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.

b. explain that bathing destroys evidence. d. offer the victim a shower after evidence is collected.

An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

b. hallucinogen ingestion.

Police bring a patient to the emergency department after an automobile accident. The patient demonstrates poor coordination and slurred speech but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? The patient a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.

b. has a high tolerance to alcohol.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

b. have someone bring the patient to the clinic immediately.

A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

b. hypertensive crisis.

A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

b. impaired social interaction.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

b. invites the patient to sit together and look at new fashion magazines.

An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.

b. maintaining physiological stability.

survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? The patient will a. facilitate counseling for the abuser. b. name two community resources for help. c. demonstrate insight into the abusive relationship. d. reexamine cultural beliefs about marital co

b. name two community resources for help.

Symptoms of withdrawal from opioids for which the nurse should assess include a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.

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.

b. not to skip meals or restrict food.

Personality traits most likely to be documented regarding a patient demonstrating characteristics of an obsessive-compulsive personality disorder are a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

b. perfectionist, inflexible.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should a. maintain a stern and authoritarian affect. b. provide care in a matter-of-fact manner. c. encourage the patient to express anger. d. be very rigid and challenging.

b. provide care in a matter-of-fact manner.

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.

b. provide written information about physical and emotional reactions the person may experience.

A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n) a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

b. sedative, such as lorazepam or chlordiazepoxide.

A patient asks for information about AA. Select the nurse's best response. "AA is a a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers."

b. self-help group for which the goal is sobriety."

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as a. denial. b. splitting. c. defensive. d. reaction formation.

b. splitting.

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.

b. states, "I feel bugs crawling on my legs and biting me."

Which hallucination necessitates the nurse to implement safety measures? The patient says, a."I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

b. "The voices say everyone is trying to kill me."

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

b. Careful observation and supervision

A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

b. Dangerous

A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

b. Darting eyes, tilted head, mumbling to self

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Constipation b. Gynecomastia c. Visual changes d. Photosensitivity

b. Gynecomastia

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident? a. Visual hallucinations b. Magical thinking c. Idea of reference d. Thought insertion

b. Magical thinking

A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

b. Olanzapine

A patient diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

b. Tardive dyskinesia

A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a. Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b. Tell the client, "You are in a safe place where you will be helped." c. Administer a prn dose of an antipsychotic medication. d. Tell the client, "You don't need to worry about that."

b. Tell the client, "You are in a safe place where you will be helped."

A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Waxy flexibility c. Depersonalization d. Thought withdrawal

b. Waxy flexibility

2. A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as a. echolalia. b. an idea of reference. c. a delusion of infidelity. d. an auditory hallucination.

b. an idea of reference.

A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will a. demonstrate increased interest in the environment by the end of week 1. b. perform self-care activities with coaching by the end of day 3. c. gradually take the initiative for self-care by the end of week 2. d. accept tube feeding without objection by day 2.

b. perform self-care activities with coaching by the end of day 3.

1. A patient has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this patient shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a. "Everyone here is trying to help you. No one wants to harm you." b."Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b."Feeling that people want to destroy you must be very frightening."

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you."

An adolescent acts out in disruptive ways. When this adolescent threatens to throw a heavy pool ball at another adolescent, which comment by the nurse would set appropriate limits? a. "Attention everyone: we are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

c. "Do not throw the ball. Put it back on the pool table."

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

c. "I felt empty and wanted to hurt myself, so I called you."

A patient is pacing the hall near the nurses' station, swearing loudly. An appropriate initial intervention for the nurse would be to address the patient by name and say: a. "What is going on?" b. "Please be quiet and sit down in this chair immediately." c. "I'd like to talk with you about how you're feeling right now." d. "You must go to your room and try to get control of yourself."

c. "I'd like to talk with you about how you're feeling right now."

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."

c. "I'm sleeping better although I still have an occasional nightmare."

16. An adolescent was recently diagnosed with ODD. The parents say to the nurse, "Isn't there some medication that will help with this problem?" Select the nurse's best response. a. "There are no medications to treat this problem. This diagnosis is behavioral in nature." b. "It's a common misconception that there is a medication available to treat every health problem." c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d. "There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you."

c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use."

A new patient beginning an alcohol rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Which responses by the nurse will be most therapeutic? (Select all that apply.) a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening."

A patient being treated for depression has taken sertraline daily for a year. The patient calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the patient to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider."

A cognitively impaired patient has been a widow for 30 years. This patient frantically tries to leave the facility, saying, "I have to go home to cook dinner before my husband arrives from work." To intervene with validation therapy, the nurse will say: a. "You must come away from the door." b. "You have been a widow for many years." c. "You want to go home to prepare your husband's dinner?" d. "Your husband gets angry if you do not have dinner ready on time?"

c. "You want to go home to prepare your husband's dinner?"

After an assault by a patient, a nurse has difficulty sleeping, startles easily, and is preoccupied with the incident. The nurse said, "That patient should not be allowed to get away with that behavior." Which response poses the greatest barrier to the nurse's ability to provide therapeutic care? a. Startle reactions b. Difficulty sleeping c. A wish for revenge d. Preoccupation with the incident

c. A wish for revenge

Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group b. A mental health center c. A women's shelter d. Vocational counseling

c. A women's shelter

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patient's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

c. Ability to provoke interpersonal conflict

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

c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips

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

c. Agnosia

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. 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

c. Anorexia nervosa

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, and an apple

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

c. Communication deficits

Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, "I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family." Which nursing diagnosis is most applicable? a. Chronic low self-esteem related to role within the family b. Decisional conflict related to compliance with school requirements c. Defensive coping related to adjustment to changes in family relationships d. Disturbed personal identity related to self-perceptions of changing family dynamics

c. Defensive coping related to adjustment to changes in family relationships

An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Disturbed personal identity related to acting out as evidenced by prostitution b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents c. Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another

c. Defensive coping related to inappropriate methods of seeking parental attention as evidenced by acting out

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional

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

c. External controls are necessary due to failure of internal control.

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 c. Honeymoon d. Stabilization

c. Honeymoon

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

c. Hyperactivity; not eating and sleeping

The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.) a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

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

c. Lanugo

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

c. Memantine

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

c. Middle

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

c. Olanzapine

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

c. Paranoid delusions of being followed by alien monsters

An emergency department nurse realizes that the spouse of a patient is becoming increasingly irritable while waiting. Which intervention should the nurse use to prevent further escalation of the spouse's anger? a. Offer the waiting spouse a cup of coffee. b. Explain that the patient's condition is not life threatening. c. Periodically provide an update and progress report on the patient. d. Suggest that the spouse return home until the patient's treatment is complete.

c. Periodically provide an update and progress report on the patient.

An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, 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. Physical

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

c. Poor judgment and hyperactivity

The plan of care for a patient in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met.

An adolescent diagnosed with a CD stole and wrecked a neighbor's motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent's reaction? a. Serotonin dysregulation and increased testosterone activity impair one's capacity for remorse. b. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy.

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

c. Relaxation techniques

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

c. Report the suspicion according to state regulations.

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

c. Say to the patient, "I must watch you take the medication. Please take it now."

A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

c. Self-assess personal attitude, values, and beliefs about this health problem.

Two patients in a residential care facility are diagnosed with 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."

c. Separate and distract the patients. Take one to the day room and the other to an activities area.

Major depressive disorder resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

c. Situational low self-esteem

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

c. Tactile hallucinations

An 11-year-old diagnosed with ODD becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a. Ignore the child's behavior. b. Send the child to time-out for 2 hours. c. Take the child to the gym and engage in an activity. d. Role-play a more appropriate behavior with the child.

c. Take the child to the gym and engage in an activity.

A patient diagnosed with major depressive disorder received six ECT sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The patient needs time to readjust to a pressured work schedule.

c. Temporary memory impairments and confusion may occur with ECT.

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

c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

c. Verbal abuse of another patient

A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? a. A patient diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the patient remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality.

Family members describe the patient as "a difficult person who finds fault with others." The patient verbally abuses nurses for their poor care. The most likely explanation lies in a. poor childrearing that did not teach respect for others. b. automatic thinking leading to cognitive distortions. c. a personality style that externalizes problems. d. delusions that others wish to deliver harm.

c. a personality style that externalizes problems.

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

c. acknowledge manipulative behavior when it is called to his or her attention.

The history shows that a newly admitted patient is impulsive. The nurse would expect behavior characterized by a. adherence to a strict moral code. b. manipulative, controlling strategies. c. acting without thought on urges or desires. d. postponing gratification to an appropriate time.

c. acting without thought on urges or desires.

One month ago, a patient diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the patient phones to say, "I feel empty and want to hurt myself." The nurse should a. arrange for emergency inpatient hospitalization. b. send the patient to the crisis intervention unit for 8 to 12 hours. c. assist the patient to choose coping strategies for triggering situations. d. advise the patient to take an antianxiety medication to decrease the anxiety level.

c. assist the patient to choose coping strategies for triggering situations.

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.

c. bruises on extremities.

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using a. psychoanalytic therapy. b. desensitization therapy. c. cognitive-behavioral therapy. d. alternative and complementary therapies.

c. cognitive-behavioral therapy.

The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

c. consider each diagnosis primary and provide simultaneous treatment.

A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

c. explain the time lag before antidepressants relieve symptoms.

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol withdrawal delirium. d. is having an acute psychosis.

c. has symptoms of alcohol withdrawal delirium.

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.

c. how to recognize hypokalemia.

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a. clonazepam b. risperidone c. lamotrigine d. aripiprazole

c. lamotrigine

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

c. manipulative

A nurse conducting group therapy on the eating-disorder 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. promoting processing of anxiety associated with eating. d. focusing on weight con

c. promoting processing of anxiety associated with eating.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

c. putting a blanket around the patient and walking with the patient to a quiet room.

A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

c. reporting increased suicidal thoughts.

A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by a. gently touching the patient's arm. b. asking the patient, "What do you need?" c. saying to the patient, "This is a safe place." d. directing the patient to cease the behavior.

c. saying to the patient, "This is a safe place."

A patient diagnosed with a somatic symptom disorder says, "My pain is from an undiagnosed injury. I can't take care of myself. I need pain medicine six or seven times a day. I feel like a baby because my family has to help me so much." It is important for the nurse to assess a. mood. b. cognitive style. c. secondary gains. d. identity and memory.

c. secondary gains.

To assist patients diagnosed with somatic symptom disorders, nursing interventions of high priority a. explain the pathophysiology of symptoms. b. help these patients suppress feelings of anger. c. shift focus from somatic symptoms to feelings. d. investigate each physical symptom as it is reported.

c. shift focus from somatic symptoms to feelings.

A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication.

c. substance addiction.

A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

c. teach the patient strategies to manage postural hypotension.

A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other patients to play cards with you."

c. "I'll stay with you. Focus on what we are talking about, not the voices. "

14. A nurse educates a patient about the antipsychotic medication regime. Afterward, which comment by the patient indicates the teaching was effective? a. "I will need higher and higher doses of my medication as time goes on." b. "I need to store my medication in a cool dark place, such as the refrigerator." c. "Taking this medication regularly will reduce the severity of my symptoms." d. "If I run out or stop taking my medication, I will experience withdrawal symptoms."

c. "Taking this medication regularly will reduce the severity of my symptoms."

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

c. Avoidant

A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

c. Physiological

The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

c. Poor personal hygiene

Which finding constitutes a negative symptom associated with schizophrenia? a. Hostility b. Bizarre behavior c. Poverty of thought d. Auditory hallucinations

c. Poverty of thought

A patient diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d.Akathisia

c. Pseudoparkinsonism

A patient diagnosed with schizophrenia begins a new prescription for ziprasidone. The patient is 5'6'' and currently weighs 204 lbs. The patient has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the patient's plan of care? a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies d. Teaching to limit caffeine intake

c. Weight management strategies

A nurse finds a patient diagnosed with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. I am afraid you will lose more weight." c. "Let's discuss the relationship between exercise, weight loss, and the effects on your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

A psychiatric clinical nurse specialist uses cognitive-behavioral therapy for 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 foods that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

d. "Being thin doesn't seem to solve your problems. You are thin now but still unhappy."

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."

d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

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

d. "I hit because I am tired of being nagged. My spouse deserves the beating."

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

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."

d. "It is disappointing when someone you love no longer recognizes you."

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

d. "Make your loved one responsible for the consequences of behavior."

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."

d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

A patient diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

d. "Tell me what happened the last time you drank."

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."

d. "You feel as though this would not have happened if you had not been alone."

Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability.

d. Achieve physiological stability.

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

d. Agnosia

A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

d. Amphetamines

A 12-year-old has engaged in bullying for several years. The parents say, "We can't believe anything our child says." Recently this child shot a dog with a pellet gun and set fire to a neighbor's trash bin. The child's behaviors support the diagnosis of a. ADHD. b. intermittent explosive disorder. c. oppositional defiant disorder (ODD). d. CD.

d. CD.

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

d. Cardiovascular

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

d. Consider the need to check the lithium level. The patient may not be swallowing medications.

A patient with severe burn injuries is irritable, angry, and belittles the nurses. As a nurse changes a dressing, the patient screams, "Don't touch me! You are so stupid. You will make it worse!" Which action by the nurse will best help to diffuse the patient's anger? a. Stop the dressing change and say, "I will leave the supplies so that you can change your own dressing." b. Continue the dressing change and say, "This dressing change is necessary because you were careless with fire." c. Discontinue the dressing change, tell the patient, "I will return when you gain control of yourself," and leave the room. d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

d. Continue the dressing change and say, "Dressing changes are needed to prevent infection. What are your ideas about how to make it less painful?"

The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child's plan of care will be provided by an advanced practice nurse rather than a staff nurse? a. Leading an activity group b. Providing positive feedback c. Formulating nursing diagnoses d. Dialectical behavioral therapy (DBT)

d. Dialectical behavioral therapy (DBT)

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

d. Drowsiness, constricted pupils, slurred speech

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.

d. Factitious disorders are under voluntary control, whereas somatic symptom disorders involve expression of psychological stress through somatization.

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

d. Heart failure

An adolescent diagnosed with an impulse control disorder says, "I want to die. I spend my time getting even with people who hurt me." When asked about a suicide plan, the adolescent replies, "I'll jump from a bridge near my home. My father threw kittens off that bridge and they died." Rate the suicide risk. a. Absent b. Low c. Moderate d. High

d. High

A patient with fears of serious heart disease was referred to the mental health center by a cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, "My chest is tight, and my heart misses beats. I'm often absent from work. I don't go out much because I need to rest." Which health problem is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)

d. Illness anxiety disorder (hypochondriasis)

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

d. Imbalanced nutrition: less than

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

d. Imbalanced nutrition: less than body requirements

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

d. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

A patient diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone

d. Naltrexone

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

d. Patient expresses satisfaction with body appearance

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

d. Physical injuries

A patient diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

d. Residential program

A patient admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

d. Risk for injury

A patient was arrested for breaking windows in the home of a former domestic partner. The patient's history also reveals childhood abuse by a punitive parent, torturing family pets, and an arrest for disorderly conduct. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Risk for other-directed violence

d. Risk for other-directed violence

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

d. Severe

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

d. Systolic blood pressure 62 mm Hg

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

d. The patient agrees to a follow-up appointment with a rape victim advocate.

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient's action? a. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. b. Crowding in skilled nursing facilities increases an individual's tendency toward violence. c. The patient learned violent behavior by watching other patients act out. d. The patient interpreted the UAP's behavior as potentially harmful.

d. The patient interpreted the UAP's behavior as potentially harmful.

A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

d. Urinary retention

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

d. arrange for one-on-one supervision.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin b. clonidine c. risperidone d. carbamazepine

d. carbamazepine

A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

d. confers with a pharmacist when selecting over-the-counter medications.

A nurse determines desired outcomes for a patient diagnosed with schizotypal personality disorder. Select the best outcome. The patient will a. adhere willingly to unit norms. b. report decreased incidence of self-mutilative thoughts. c. demonstrate fewer attempts at splitting or manipulating staff. d. demonstrate ability to introduce self to a stranger in a social situation.

d. demonstrate ability to introduce self to a stranger in a social situation.

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.

d. exhibiting clues to potential aggression.

A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to a. an inherited disorder that manifests itself as an incapacity to tolerate stress. b. use of projective identification and splitting to bring anxiety to manageable levels. c. a constitutional inability to regulate affect, predisposing to psychic disorganization. d. fear of abandonment associated with progress toward autonomy and independence.

d. fear of abandonment associated with progress toward autonomy and independence.

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.

d. gain 1 to 2 pounds.

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

d. grandiosity, self-importance, and a sense of entitlement.

A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that the patient a. sees a relationship between symptoms and interpersonal conflicts. b. has little difficulty communicating emotional needs to others. c. rarely derives personal benefit from the symptoms. d. has altered comfort and activity needs.

d. has altered comfort and activity needs.

A nursing diagnosis for a patient diagnosed 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.

d. identify two alternative methods of coping with loneliness.

A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration.

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

d. lack of guilt feelings.

An emergency code was called after a patient pulled a knife from a pocket and threatened, "I will kill anyone who tries to get near me." The patient was safely disarmed and placed in seclusion. Justification for use of seclusion was that the patient a. was threatening to others. b. was experiencing psychosis. c. presented an undeniable escape risk. d. presented a clear and present danger to others.

d. presented a clear and present danger to others.

Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. b. offer to stay with the patient until stability is regained. c. advise the patient to try not to think about the assault. d. provide referral information verbally and in writing.

d. provide referral information verbally and in writing.

To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should understand that patients have difficulty giving up the symptoms because the symptoms a. are generally chronic. b. have a physiological basis. c. can be voluntarily controlled. d. provide relief from health anxiety.

d. provide relief from health anxiety.

A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression.

d. respiratory depression.

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

d. socially anxious, rambling stories, peculiar ideas.

Which information from a patient's record would indicate marginal coping skills and the need for careful assessment of the risk for violence? A history of a. academic problems. b. family involvement. c. childhood trauma. d. substance abuse.

d. substance abuse.

For which behavior would limit setting be most essential? The patient who a. clings to the nurse and asks for advice about inconsequential matters. b. is flirtatious and provocative with staff members of the opposite sex. c. is hypervigilant and refuses to attend unit activities. d. urges a suspicious patient to hit anyone who stares.

d. urges a suspicious patient to hit anyone who stares.

A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's most therapeutic response. a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

d. "I am having difficulty understanding what you are saying."

A patient diagnosed with schizophrenia anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a. "How long has the voice been directing your behavior?" b. "Does what the voice tell you to do frighten you?" c. "Do you recognize the voice speaking to you?' d. "What is the voice telling you to do?"

d. "What is the voice telling you to do?"

A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's most therapeutic response. a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

d. "You're laughing. Tell me what's happening."

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

d. Aripiprazole

A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d. Associative looseness

A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective? a. Suggest analogies that might apply to a common daily problem. b. Assign each participant a problem to solve independently and present to the group. c. Ask each patient to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.

d. Invite participants to come up with solution to getting incorrect change for a purchase.

A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a. Agranulocytosis; institute reverse isolation. b. Tardive dyskinesia; withhold the next dose of medication. c. Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d. Neuroleptic malignant syndrome; notify health care provider stat.

d. Neuroleptic malignant syndrome; notify health care provider stat.

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c.Neologisms d. Paranoia

d. Paranoia

The nurse is developing a plan for psychoeducational sessions for a small group of adults diagnosed with schizophrenia. Which goal is best for this group? Members will a. gain insight into unconscious factors that contribute to their illness. b. explore situations that trigger hostility and anger. c. learn to manage delusional thinking. d. demonstrate improved social skills.

d. demonstrate improved social skills.

A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should a. sit close to the patient. b. place an arm protectively around the patient's shoulders. c. place a hand on the patient's arm and exert light pressure. d. maintain a normal social interaction distance from the patient.

d. maintain a normal social interaction distance from the patient.

What is the priority need for a patient diagnosed with severe, 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

d. maintenance of nutrition and hydration

A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of a. the need for psychoeducation. b. medication nonadherence. c. chronic deterioration. d. relapse.

d. relapse.

A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. make observations about the patient's poor personal hygiene. d. firmly and neutrally assist the patient with showering.

firmly and neutrally assist the patient with showering.

A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The patient says, "Although I'm still having pain, I notice it less and am able to perform more activities." The nurse should evaluate the treatment plan as a. marginally successful. b. minimally successful. c. partially successful. d. totally achieved.

partially successful.