Mental Health Unit IV (CH 18, 20, 22, 24, 28, 29): questions from Quizlet, end-of-chapter, and online resources NCLEX questions (but NOT online resources pre- or post-test questions)
5. Which racial identification places a woman at the greatest risk of being sexually assaulted in her lifetime? a. Multiracial b. American Indian c. Black non-Hispanic d. Caucasian
ANS: A
Patients diagnosed with BPD exhibit negative effect, which includes rapidly moving from one emotional extreme to another. What term is used to describe this characteristic? A. Lability B. Impulsivity C. Splitting D. Denial
ANS: A One of pathological personality traits seen in persons with BPD is negative effect, which is characterized by emotional lability, that is, rapidly shifting emotions from one extreme to another. Patients exhibiting this trait are often documented as being labile. None of the other options is used to describe this characteristic.
Which of the following are myths surrounding rape? Select all that apply. A. Women are usually raped by a stranger. B. Women do not "ask" to be raped by their behavior or dress. C. Most rapes occur away from home areas such as alleys and behind buildings. D. Documented rape cases include women from 8 to 70 years old. E. Rape is an expression of aggression and anger. F. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. G. Unless the assailant is armed, most women should be able to get away and avoid the rape.
ANS: A, C, D, E, F, G It is true that women do not "ask to be raped" by behaving or dressing in a particular manner. The other options are untrue statements.
1. Which statement made by the psychiatric nurse demonstrates an accurate understanding of the factors that affect an individual's personality? a. "Therapy will help her identify that her problems are personality related." b. "I'll need to learn more about this patient's cultural beliefs." c. "It's encouraging to know that personality disorders respond well to treatment." d. "A person's personality is fluid and adjusts to current social situations."
ANS: B
10. Pedophilic disorder is the most common paraphilic disorder where adults who have a primary or exclusive sexual preference for prepubescent children. A subset of this disorder is termed hebephilia and is defined as attraction to: a. Infants b. Pubescent individuals c. Teens between the ages of 15 and 19 d. Males only
ANS: B
22. A man who reports frequently experiencing premature ejaculation tells the nurse, I feel like such a failure. Its so awful for both me and my partner. Can you help me? Select the nurses best response. a. Have you discussed this problem with your partner? b. I can refer you to a practitioner who can help you with this problem. c. Have you asked your health care provider for prescription medication? d. There are several techniques described in this pamphlet that might be helpful.
ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurses role.
20. A man with hypospadias tells the nurse, Intercourse with my new bride is painful. Which term applies to the patients complaint? a. Delayed ejaculation b. Erectile dysfunction c. Premature ejaculation d. Genito-pelvic pain/penetration disorder
ANS: D This sexual pain is genito-pelvic pain/penetration disorder and may occur in men or women. The individual feels pain in the genitals during intercourse. Erectile or ejaculation problems are not evident.
Which statement is true regarding antisocial personality disorder (APD)? Select all that apply. A. It is the least studied of the personality disorders. B. It is characterized by rigidity and inflexible standards of self and others. C. Persons with APD display magical thinking. D. Persons with APD are concerned with personal pleasure and power. E. It is characterized by deceitfulness, disregard for others, and manipulation. F. Persons with APD usually present for treatment because of awareness of how their behavior is affecting others. G. Frontal lobe dysfunction is a brain change identified in APD.
ANS: D, E, G APD is the most studied and researched personality disorder. Rigidity and inflexible standards describe obsessive-compulsive personality disorder. Magical thinking describes STPD. People with APD usually present with depression because of the consequences of their behaviors, not because they care about the effects of their actions on others.
5. A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Anger b. Concern c. Empathy d. Compassion
ANS: A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.
20. Physical assessment of a patient diagnosed with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. 25% underweight.
ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and not usually seen in bulimia.
21. A man who regularly experiences premature ejaculation tells the nurse, I feel like such a failure. Its so awful for both me and my partner. Select the nurses most therapeutic response. a. I sense you are feeling frustrated and upset. b. Tell me more about feeling like a failure. c. You are too hard on yourself. d. What do you mean by awful?
ANS: A Using reflection and empathy promotes trust and conveys concern to the patient. The distracters do not offer empathy, probe, and offer premature reassurance.
1. A patient with a history of daily alcohol abuse was hospitalized at 0200 today. When would the nurse expect withdrawal symptoms to peak? a. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) b. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) c. About 0200 on hospital day 3 (72 hours after drinking stopped) d. About 0200 on hospital day 4 (96 hours after drinking stopped)
ANS: B Alcohol withdrawal usually begins 6 to 8 hours after cessation or significant reduction of alcohol intake. It peaks between 24 and 48 hours, then resolves or progresses to delirium.
8. Terry is a young male in a chemical dependency program. Recently he has become increasingly distracted and disengaged. The nurse concludes that Terry is: a. Bored b. Depressed c. Bipolar d. Not ready to change
ANS: D
16. 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. Im 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 wasnt home.
ANS: C Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.
23. 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. Lets 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.
ANS: D A matter-of-fact statement that the nurses perceptions are different will help to avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.
Which of the following persons has the highest risk factors for physical abuse? A. Emma, a 7-month-old baby who has colic and doesn't sleep through the night B. Roland, a 53-year-old man with cardiovascular disease living with his son C. Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder D. Rose, a 77-year-old woman living with her daughter and son-in-law
ANS: D Older women dependent on family members for care are at higher risk for abuse. The other options do not describe specific characteristics that put them at higher risk for abuse.
21. Select the nursing intervention necessary after administering naloxone (Narcan) to a patient experiencing an opiate overdose. a. Monitor the airway and vital signs every 15 minutes. b. Insert a nasogastric tube and test gastric pH. c. Treat hyperpyrexia with cooling measures. d. Insert an indwelling urinary catheter.
ANS: A Narcotic antagonists such as naloxone quickly reverse CNS depression; however, because the narcotics have a longer duration of action than antagonists, the patient may lapse into unconsciousness or require respiratory support again. The incorrect options are measures unrelated to naloxone use.
21. 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
ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the rule.
10. You are working at a telephone hotline center when Abby, a rape victim, calls. Abby states she is afraid to go to the hospital. What is your best response? a. "I'm here to listen, and we can talk about your feelings." b. "You don't need to go to the hospital if you don't want to." c. "If you don't go to the hospital, we can't collect evidence to help convict your rapist." d. "Why are you afraid to seek medical attention?"
ANS: A
2. When considering an eating disorder, what is a physical criterion for hospital admission? a. A daytime heart rate of less than 50 beats per minute b. An oral temperature of 100°F or more c. 90% of ideal body weight d. Systolic blood pressure greater than 130 mm Hg
ANS: A
3. What is the current accepted professional view of the effect of culture on the development of a personality disorder? a. There aren't sufficient studies to confirm the role that ethnicity and race have on the prevalence of personality disorders. b. The North American and Australian cultures produce higher incidences of personality disorders among their populations. c. Neither culture nor ethnic background is generally considered in the development of personality disorders. d. Personality disorders have been found to be primarily the products of genetic factors, not cultural factors.
ANS: A
4. Which statement describes a common sexual side effect of diazepam (Valium)? a. "I'm just not interested in sex as much." b. "I'm experiencing vaginal dryness." c. "I don't have organisms anymore." d. "My breasts have gotten larger."
ANS: A
5. Which patient statement supports the diagnosis of anorexia nervosa? a. "I'm terrified of gaining weight." b. "I wish I had a good friend to talk to." c. "I've been told I drink way too much alcohol." d. "I don't get much pleasure out of life anymore."
ANS: A
6. Which patient has the greatest risk for suicide? a. A patient who expresses the inability to stop searching the internet for child pornography. b. A patient who reports having lost interest in having a sexual relationship with his wife. c. A patient with a history of exposing himself to female strangers on the bus. d. A patient whose attraction to prepubescent girls has increased.
ANS: A
7. Taylor, a psychiatric registered nurse, orients Regina, a patient with anorexia nervosa, to the room where she will be assigned during her stay. After getting Regina settled, the nurse informs Regina: a. "I need to go through the belongings you have brought with you." b. "You can use the scale in the back room when you need to." c. "You will be eating five times a day here." d. "The daily structure is based around your desire to eat."
ANS: A
7. The use of a patient-centered interview technique works well for gathering information about abusive situations. It is a good use of clinical time to sit near the patient and: a. Establish trust and rapport b. Ask lots of questions c. Interrupt the patients' story to allow for decompression d. Utilize closed-ended questions
ANS: A
8. Connor is a 28-year-old student, referred by his university for a psychiatric evaluation. He reports that he has no friends at the university and people call him a loner. Recently, Connor has been giving lectures to pigeons at the university fountains. Connor is diagnosed as schizotypal, which differs from schizophrenia in that persons diagnosed as schizotypal: a. Can be made aware of their delusions b. Are far more delusional than schizophrenics c. Have a greater need for socialization d. Do not usually respond to antipsychotic medications
ANS: A
9. A male arrested for inappropriate sexual contact in a subway car denies the allegation. Upon interviewing the man, the nurse suspects frotteuristic disorder due to his: a. Lack of relationships b. Overall aggressive nature c. Criminal history including robbery d. Intense hatred of women
ANS: A
9. Malika has been overweight all of her life. Now an adult, she has health problems related to her excessive weight. Seeking weight loss assistance at a primary care facility Malika is surprised when the nurse practitioner suggests: a. A trial of SSRI antidepressant therapy b. Mild exercise to start, increasing in intensity over time c. Removing snack foods from the home d. Medication treatment for hypertension
ANS: A
1. 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
ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.
24. A patient approaches the nurse in the clinic waiting room and says, I want to talk to you about a sexual matter. The nurse can best facilitate the discussion by: a. saying, Lets go my office. b. responding, I want to help. Go ahead; Im listening. c. telling the patient, Lets schedule another appointment. d. offering to sit in a corner of the waiting room with the patient.
ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The distracters block communication.
18. An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult: a. consistently avoids schools and shops at malls only during school hours. b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.
ANS: A One strategy for avoiding acting on inappropriate urges is to avoid environments and circumstances that evoke those urges; for a pedophile this would include avoiding all situations that would likely result in contact with children. Pedophilic disorder is persistent; elimination of fantasies about children would be unrealistic. A person who volunteers to lead a scout troop is placing himself/herself around children. A diminished sex drive or a healthy sex life with an appropriate partner does not necessarily reduce the desire for sexual contact with children.
14. A man says, I enjoy watching women when I am out in public. I like to go to places where I can observe women crossing their legs in hopes of seeing something good. Which statement about this behavior is most accurate? a. It is a sexual disorder. The behavior is socially atypical. It could disrupt relationships and could be insulting to others. b. It is not a sexual disorder. These events occur in public, where those he observes do not have a reasonable expectation of privacy. c. It is not a sexual disorder. Because it occurs in public areas, this behavior does not hurt others or involve intrusion into the personal space of those observed. d. An action is or is not a sexual disorder depending on applicable local laws, so whether this meets the definition of a sexual disorder depends on the location.
ANS: A A sexual disorder is defined as an activity that is socially atypical, has the potential to disrupt significant relationships, and may result in insult or injury to others. The behavior described constitutes a sexual disorder (voyeurism). Although laws vary, an act does not have to be illegal to constitute a sexual disorder. The fact that the behavior occurs in a public setting could have a bearing on whether it is illegal, but not on whether it is considered to be a sexual disorder.
18. Which statement most accurately describes substance addiction? a. It is a lack of control over use. Tolerance, craving, and withdrawal symptoms occur when intake is reduced or stopped. b. It occurs when psychoactive drug use interferes with the action of competing neurotransmitters. c. Symptoms occur when two or more drugs that affect the central nervous system (CNS) have additive effects. d. It involves using a combination of substances to weaken or inhibit the effect of another drug.
ANS: A Addiction involves a lack of control over substance use, as well as tolerance, craving, and withdrawal symptoms when intake is reduced or stopped.
23. A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with boys who are athletic d. Intense urges to watch his parents have sex
ANS: A An individual with gender dysphoria feels at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender dysphoria.
23. 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.
ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.
Which statement is true of pharmacological therapies associated with the treatment of personality disorders? A. Although there are no FDA-approved drugs specific to the treatment of personality disorders, patients benefit from specific off-label uses of antipsychotics, mood stabilizers, and antidepressants, depending on which personality disorder is evident. B. Research has shown that currently available psychotropic drugs have not been shown to be effective in treating personality disorders. C. Patients with narcissistic personality disorder and obsessive-compulsive personality disorder have shown the most benefit from the use of antianxiety medications along with use of selective serotonin reuptake inhibitors. D. Patients with personality disorders have been shown to be resistant to accepting medication, and as a result most providers do not prescribe psychotropic drugs to these patients.
ANS: A At this time in the United States, there are no specifically FDA-approved medications for treating personality disorders. Prescribers are using the medications "off-label" until evidence-based pharmacotherapies are proven to be safe and effective. There is evidence that mood stabilizers, antidepressants, and atypical antipsychotics are helpful in specific personality disorders. Pharmacologic evidence is lacking for the treatment of persons with narcissistic and obsessive-compulsive personality disorders. Although patients with personality disorders usually do not like taking medicine unless it calms them down and are fearful about taking something over which they have no control, providers do attempt to mediate symptoms with psychotropic agents for improved quality of life.
14. The treatment team plans care for a person diagnosed with schizophrenia and cannabis abuse. The person has recently used cannabis daily and is experiencing increased hallucinations and delusions. Which principle applies to care planning? a. Consider each disorder primary and provide simultaneous treatment. b. The person will benefit from treatment in a residential treatment facility. c. Withdraw the person from cannabis, and then treat the schizophrenia. d. Treat the schizophrenia first, and then establish the goals for the treatment of substance abuse.
ANS: A Dual diagnosis (co-occurring disorders) clinical practice guidelines for both outpatient and inpatient settings suggest that the substance disorder and the psychiatric disorder should both be considered primary and receive simultaneous treatments. Residential treatment may or may not be effective.
23. A nurse with a history of narcotic abuse is found unconscious in the hospital locker room after overdosing. The nurse is transferred to an inpatient substance abuse unit for care. Which attitudes or behaviors by nursing staff may be enabling? a. Conveying understanding that pressures associated with nursing practice underlie substance abuse. b. Pointing out that work problems are the result, but not the cause, of substance abuse. c. Conveying empathy when the nurse discusses fears of disciplinary action by the state board of nursing. d. Providing health teaching about stress management.
ANS: A Enabling denies the seriousness of the patient's problem or supports the patient as he or she shifts responsibility from self to circumstances. The incorrect options are therapeutic and appropriate.
13. A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patients sexual practices? a. Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern? b. Sexual health can reflect a number of medical problems, so Id like to ask if you have any sexual problems you think we should know about. c. Its your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please? d. I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment.
ANS: A Explaining that sexual practices vary helps reduce patient anxiety about the topic by normalizing the full range of sexual practices so that whatever his situation, the patient can feel comfortable sharing it. Its your business of course implies the nurse does not have a valid reason to seek the information and in effect suggests that the patient perhaps should not answer the question. It might be helpful makes the information seem less valid or important for the nurse to pursue and, again, could discourage the patient from responding fully. Asking if the patient has any sexual problems that staff should know about is not unprofessional, but it is a very broad question that may increase a patients uncertainty about what the nurse wants to hear, thus increasing his anxiety. Defining or giving an example of sexual problem would make this inquiry more effective.
14. 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.
ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. Often the triggers are anxiety-producing situations. Identification of triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes highest priority.
12. 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 nurses 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.
ANS: A In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assumption of a parental role. Protective behaviors are part of the parents role. The helpful nurse uses a problem-solving approach and focuses on the patients feelings of shame and low self-esteem. Referring a patient to a self-help group is an appropriate intervention.
26. Three months ago a patient diagnosed with binge eating disorder weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which current assessment finding indicates the need for reevaluation of this treatment approach? The patient: a. now weighs 196 pounds. b. says, I am using contraceptives. c. says, I feel full after eating a small meal. d. reports problems with dry mouth and constipation.
ANS: A Lorcaserin is designed to make people feel full after eating smaller meals by activating a serotonin 2c receptor in the brain and blocking appetite signals. According to the FDA, this drug should be stopped if a patient does not have 5% weight loss after 12 weeks of use. If the patient now weighs 196 pounds, the medication has not been effective. The distracters indicate patient learning was effective and expected side effects of this medication.
39. A patient in an alcohol treatment program says, "I have been a loser all my life. I'm so ashamed of what I have put my family through. Now, I'm not even sure I can succeed at staying sober." Which nursing diagnosis applies? a. Chronic low self-esteem b. Situational low self-esteem c. Disturbed personal identity d. Ineffective health maintenance
ANS: A Low self-esteem is present when a patient sees himself or herself as inadequate. It is a chronic problem because it is a lifelong feeling for the patient. Data are not present to support the other options.
Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present with which assessment characteristic? A. Vague physical complaints such as insomnia or pain B. Extreme anger and unpredictable behavior C. Family members described as supportive D. Psychosis and/or mania as a result of long-term abuse
ANS: A Patients may present with symptoms that may be vague and can include chronic pain, insomnia, hyperventilation, or gynecological problems. Attention to the interview process and setting is important to facilitate accurate assessment of physical and behavioral indicators of family violence. Presenting with extreme anger is possible but not as common as presenting with vague physical complaints. Having many family members there is unlikely as many victims keep their history of being battered a secret. It is not known that psychosis or mania is a result of physical violence, and this would not be a usual presenting complaint.
3. An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, I havent had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I dont know if my heart is strong enough. Which nursing diagnosis applies? a. Deficient knowledge related to faulty perception of health status b. Disturbed self-concept related to required lifestyle changes c. Disturbed body image related to treatment side effects d. Sexual dysfunction related to self-esteem disturbance
ANS: A Patients who have had a myocardial infarction often believe sexual intercourse will cause another heart attack. The patient has completed the rehabilitation, but education is needed regarding sexual activity. These patients should receive information about when sexual activity may begin, positions that conserve energy, and so forth. The scenario does not suggest self-concept or body image disturbance.
33. In what significant ways is the therapeutic environment different for a patient who has ingested D-lysergic acid diethylamide (LSD) than for a patient who has ingested phencyclidine (PCP)? a. For LSD ingestion, one person stays with the patient and provides verbal support. For PCP ingestion, a regimen of limited contact with staff members is maintained, and continual visual monitoring is provided. b. For PCP ingestion, the patient is placed on one-on-one intensive supervision. For LSD ingestion, a regimen of limited interaction and minimal verbal stimulation is maintained. c. For LSD ingestion, continual moderate sensory stimulation is provided. For PCP ingestion, continual high-level stimulation is provided. d. For LSD ingestion, the patient is placed in restraints. For PCP ingestion, seizure precautions are implemented.
ANS: A Patients who have ingested LSD respond well to being "talked down" by a supportive person. Patients who have ingested PCP are very sensitive to stimulation and display frequent, unpredictable, and violent behaviors. Although one person should perform care and talk gently to the patient, no one individual should be alone in the room with the patient. An adequate number of staff members should be gathered to manage violent behavior if it occurs.
Which statement is true of the eating disorder referred to as bulimia? A. Patients with bulimia often appear at a normal weight. B. Patients with bulimia binge eat but do not engage in compensatory measures. C. Patients with bulimia severely restrict their food intake. D. One sign of bulimia is lanugo.
ANS: A Patients with bulimia are often at or close to ideal body weight and do not appear physically ill. The other options do not refer to bulimia but rather refer to signs of binge eating disorder and anorexia nervosa.
23. Which statement is a nurse most likely to hear from a patient diagnosed with anorexia nervosa? a. "I would be happy if I could lose 20 more pounds." b. "My parents don't pay much attention to me." c. "I'm thin for my height." d. "I have nice eyes."
ANS: A Patients with eating disorders have distorted body images and cognitive distortions. They see themselves as overweight even when their weight is subnormal. "I'm thin for my height" is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as "I have nice eyes." Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.
15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from: a. 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9 C; pulse, 38 beats/min; blood pressure 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36 C; pulse, 50 beats/min; blood pressure 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5 C; pulse, 60 beats/min; blood pressure 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7 C; pulse, 62 beats/min; blood pressure 74/48 mm Hg
ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36 C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.
7. 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. The psychiatrist suggests the use of a medication. Which type of medication should the nurse expect? a. Selective serotonin reuptake inhibitor (SSRI) b. Monoamine oxidase inhibitor (MAOI) c. Benzodiazepine d. Antipsychotic
ANS: A SSRIs are used to treat depression. Many patients with borderline personality disorder are fearful of taking something over which they have little control. Because SSRIs have a good side effect profile, the patient is more likely to comply with the medication. Low-dose antipsychotic or anxiolytic medications are not supported by the data given in this scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.
2. A nurse is performing an assessment for a 59-year-old man who has hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension. b. Such questions are an indirect way of learning about the patients medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.
ANS: A Some of the drugs used to treat hypertension can interfere with normal sexual functioning and lead to sexual disorders. Hypertension itself can lead to acquired erectile dysfunction. It would not be appropriate or necessary to use such inquiries as a lead-in to other sexual health topics. Sexual dysfunction, while stressful, does not cause hypertension.
27. A patient diagnosed with anorexia nervosa has a body mass index (BMI) of 14.8 kg/m2. Which assessment finding is most likely to accompany this value? a. Cachexia b. Leukocytosis c. Hyperthermia d. Hypertension
ANS: A The BMI value indicates extreme malnutrition. Cachexia is a hallmark of this problem. The patient would be expected to have leukopenia rather than leukocytosis. Hypothermia and hypotension are likely assessment findings.
28. 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 National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine
ANS: A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.
40. Which documentation indicates that the treatment plan for a patient in an alcohol treatment program was effective? a. Is abstinent for 10 days and states, "I can maintain sobriety one day at a time." Spoke with employer, who is willing to allow the patient to return to work in three weeks. b. Is abstinent for 15 days and states, "My problems are under control." Plans to seek a new job where co-workers will not know history. c. Attends AA daily; states many of the members are "real" alcoholics and says, "I may be able to help some of them find jobs at my company." d. Is abstinent for 21 days and says, "I know I can't handle more than one or two drinks in a social setting."
ANS: A The answer reflects the AA beliefs. The incorrect options each contain a statement that suggests early relapse.
8. An 11-year-old says, My parents dont like me. They call me stupid and say they wish I were never born. It doesnt matter what they think because I already know Im 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
ANS: A The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the childs statements.
6. A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression
ANS: A The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurse's advocacy role necessitates an assessment for intimate partner violence.
23. Which family scenario presents the greatest risk for family violence? a. An unemployed husband with low self-esteem, a wife who loses her job, and a developmentally delayed 3-year-old child b. A husband who finds employment 2 weeks after losing his previous job, a wife with stable employment, and a child doing well in school c. A single mother with an executive position, a talented child, and a widowed grandmother living in the home to provide child care d. A single homosexual male parent, an adolescent son who has just begun dating girls, and the father's unmarried sister who has come to visit for 2 weeks
ANS: A The family with an unemployed husband with low self-esteem, a newly unemployed wife, and a developmentally challenged young child has the greatest number of stressors. The other families described have fewer negative events occurring.
30. 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.
ANS: A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.
10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.
ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.
15. A parent who is very concerned about a 3-year-old son says, He likes to play with girls toys. Do you think he is homosexual or mentally ill? Which response by the nurse most professionally describes the current understanding of gender identity? a. A childs interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood. b. Its difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult. c. The research is incomplete, but many boys play with girls toys and turn out normal as adults. d. I am sure that whatever happens, he will be a loving son, and you will be a proud parent.
ANS: A The parents inquiry is really two questions: (1) whether the childs behavior suggests an increased risk of developing mental illness and (2) what the childs future sexual preference will be. The psychiatric disorder that most directly addresses gender preferences and cross-gender activities is gender identity disorder. Pointing out that cross-gender activities are not necessarily related to gender identity and not likely to be carried into adulthood is supported by current research. Saying the child will grow up to be normal implies that to be homosexual is to be abnormal, which reflects a cultural perspective that most professionals would believe to be inappropriate to share in a professional setting. Research provides information about the relationship between cross-gender interests in childhood and adulthood, so a comment that research is incomplete is not entirely accurate. Stating that the child is a wonderful boy the father will be proud of, whatever happens, evades the parents question and suggests that parental bonds should not be affected by gender issues. The nurse has a professional obligation to maintain an objective, therapeutic relationship.
3. A patient was admitted last night with a hip fracture sustained in a fall while intoxicated. The patient points to the Buck's traction and screams, "Somebody tied me up with ropes." The patient is experiencing: a. an illusion. b. a delusion. c. hallucinations. d. hypnagogic phenomenon.
ANS: A The patient is misinterpreting a sensory perception when seeing a noose instead of traction. Illusions are common in early withdrawal from alcohol. A delusion is a fixed, false belief. Hallucinations are sensory perceptions occurring in the absence of a stimulus. Hypnagogic phenomena are sensory disturbances that occur between waking and sleeping.
The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? A. Readiness to change and support system B. Current college performance C. Financial ability D. Availability of immediate family to come to meetings
ANS: A The plan will take into account acute safety needs, severity and range of symptoms, motivation or readiness to change, skills and strengths, availability of a support system, and the individual's cultural needs. The other options may be factors but are not the priority factors in planning interventions for the patient as much as the patient's perceived need for change and having others who can lend support outside the hospital.
4. 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. Im grossly underweight, but thats what I want. d. Im a few pounds overweight, but I can live with it.
ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell people perceptions of self. The patient with anorexia does not recognize his or her thinness and will persist in trying to lose more weight.
25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.
ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the hearts capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.
4. Which personality disorders are generally associated with behaviors described as "odd or eccentric"? Select all that apply. a. Paranoid b. Schizoid c. Histrionic d. Obsessive-compulsive e. Avoidant
ANS: A, B
5. Which behaviors are examples of a primitive defense mechanism often relied upon by those diagnosed with a personality disorder? Select all that apply. a. Regularly attempts to split the staff b. Attempts to undo feelings of anger by offering to do favors c. Regresses to rocking and humming to sooth themselves when fearful d. Lashes out verbally when confronted with criticism e. Destroys another person's belongings when angry
ANS: A, B, C
5. The nurse is assisting a patient to identify safety issues that may occur now that she has left an abusive partner. What telephone numbers should be available to the patient? Select all that apply. a. The police department b. An abuse hotline c. A responsible friend or family member d. A domestic violence shelter e. The hospital emergency department
ANS: A, B, C, D
2. 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
ANS: A, B, C, D Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder.
2. Which problem is observed in children who regularly witness acts of violence in their family? Select all that apply. a. Phobias b. Low self-esteem c. Major depressive disorder d. Narcissistic personality disorder e. Posttraumatic stress disorder
ANS: A, B, C, E
8. Safety measures are of concern in eating-disorder treatments. Patients with anorexia nervosa are supervised closely to monitor: Select all that apply. a. Foods that are eaten b. Attempts at self-induced vomiting c. Relationships with other patients d. Weight
ANS: A, B, D
1. A patient with a history of alcohol use disorder has been prescribed disulfiram (Antabuse). Which physical effects support the suspicion that the patient has relapsed? Select all that apply. a. Intense nausea b. Diaphoresis c. Acute paranoia d. Confusion e. Dyspnea
ANS: A, B, D, E
10. Perpetrators of domestic violence tend to: Select all that apply. a. Have relatively poor social skills and to have grown up with poor role models. b. Believe they, if male, should be dominant and in charge in relationships. c. Force their mates to work and expect them to handle the financial decisions. d. Be controlling and willing to use force to maintain their power in relationships. e. Prevent their mates from having relationships and activities outside the family.
ANS: A, B, D, E
4. Which signs and symptoms are associated with acute stress disorder and often observed in patients who have been sexually assaulted? Select all that apply. a. Outbursts of anger b. Depression c. Auditory hallucinations d. Flashbacks e. Amnesia for the event
ANS: A, B, D, E
3. Which medications are currently approved for the treatment of male erectile disorder? Select all that apply. a. Sildenafil (Viagra) b. Flibanserin (Addyi) c. Tadalafil (Cialis) d. Vardenafil (Levitra) e. Avanafil (Stendra)
ANS: A, C, D, E
1. A nurse assesses a patient diagnosed with pedophilic disorder. Which findings are most likely? Select all that apply. a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity
ANS: A, C, D Attention deficit hyperactivity disorder (ADHD) in childhood, substance abuse, phobic disorders, and major depression/dysthymia are strongly associated with paraphilic disorders. Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur. Patients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self-confidence is lacking; therefore, grandiosity would not be expected.
3. When considering the need for monitoring, which intervention should the nurse implement for a patient with anorexia nervosa? Select all that apply. a. Provide scheduled portion-controlled meals and snacks. b. Congratulate patients for weight gain and behaviors that promote weight gain. c. Limit time spent in bathroom during periods when not under direct supervision. d. Promote exercise as a method to increase appetite. e. Observe patient during and after meals/snacks to ensure that adequate intake is achieved and maintained.
ANS: A, C, E
2. 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.
ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.
2. 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.
ANS: A, C, E, F, G The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.
2. Which assessment data confirm the suspicion that a patient is experiencing opioid withdrawal? Select all that apply. a. Pupils are dilated b. Pulse rate is 62 beats/min c. Slow movements d. Extreme anxiety e. Sleepy
ANS: A, D
1. Which patient statement acknowledges the characteristic behavior associated with a diagnosis of pica? a. "Nothing could make me drink milk." b. "I'm ashamed of it, but I eat my hair." c. "I haven't eaten a green vegetable since I was 3 years old." d. "I regurgitate and re-chew my food after almost every meal."
ANS: B
1. Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work."
ANS: B
1. Which statement made by a sexually assaulted patient strongly suggests the drug gamma-hydroxybutyrate acid (GHB) was involved in the attack? a. "I remember everything that happened, but felt too tired to fight back." b. "The drink I was given had a salty taste to it." c. "They tell me I was unconscious for 24 hours." d. "I heard that I was fighting the nursing staff and saying that they were trying to kill me."
ANS: B
10. Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell that you are a caring person. Josie is unsure of what she wants to do with her life and her "mixed-up feelings" about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it "makes the numbness stop." Given this presentation, which personality disorder would you suspect? a. Obsessive-compulsive b. Borderline c. Antisocial d. Schizotypal
ANS: B
3. What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? a. The caregiver is a single male relative. b. The caregiver was neglected as a child. c. The caregiver is under the age of 30. d. The caregiver has little experience with the elderly.
ANS: B
3. Which statement is an accurate depiction of sexual assault? a. Rape is a sexual act. b. Most rapes occur in the home. c. Rape is usually an impulsive act. d. Women are usually raped by strangers.
ANS: B
5. A patient diagnosed with opioid use disorder has expressed a desire to enter into a rehabilitation program. What initial nursing intervention during the early days after admission will help ensure the patient's success? a. Restrict visitors to family members only. b. Manage the patient's withdrawal symptoms well. c. Provide the patient a low stimulus environment. d. Advocate for at least 3 months of treatment.
ANS: B
6. Lester and Eileen have always enjoyed gambling. Lately, Eileen has discovered that their savings account is down by $50,000. Eileen insists that Lester undergo therapy for his gambling behavior. The nurse recognizes that Lester is making progress when he states: a. "I understand that I am a bad person for depleting our savings." b. "Gambling activates the reward pathways in my brain." c. "Gambling is the only thing that makes me feel alive." d. "We have always enjoyed gaming. I do not know why Eileen is so upset."
ANS: B
6. Obesity can be the end result of a binge-eating disorder. The nurse understands that the best treatment option in persons with a binge-eating disorder promotes: a. Bariatric surgery b. Coping strategies c. Avoidance of public eating d. Appetite suppression medications
ANS: B
6. Personality disorders often co-occur with mood and eating disorders. A young woman is undergoing treatment at an eating disorders clinic and her nurse suspects the patient may also have a Cluster B personality disorder due to the young woman's: a. Desire to avoid eating b. Dramatic response to frustration c. Excessive exercise routine d. Morose personality traits
ANS: B
6. Secondary effects of abuse often manifest as arrested development in children due to the fact that: a. Coping is easier than emotional growth b. Energy for development is diverted to coping c. Children cannot differentiate love from abuse d. Abuse fosters a sense of belonging, even if dysfunctional
ANS: B
8. The abused person is often in a dependent position, relying on the abuser for basic needs. At particular risk are children and the elderly due to: a. The love they have for parents or children. b. Their limited options. c. The need to feel safe at home. d. Other relatives do not want them.
ANS: B
9. An appropriate expected outcome in individual therapy regarding the perpetrator of abuse would be: a. A decrease in family interaction so that there are fewer opportunities for abuse to occur. b. The perpetrator will recognize destructive patterns of behavior and learn alternate responses. c. The perpetrator will no longer live with the family but have supervised contact while undergoing intensive inpatient therapy. d. A triad of treatment modalities, including medication, counseling, and role-playing opportunities.
ANS: B
9. Maxwell is a 30-year-old male who arrives at the emergency department stating, "I feel like I am having a stroke." During the intake assessment, the nurse discovers that Maxwell has been working for 36 hours straight without eating and has consumed eight double espresso drinks and 12 caffeinated sodas. The nurse suspects: a. Fluid overload b. Dehydration and caffeine overdose c. Benzodiazepine overdose d. Sleep deprivation syndrome
ANS: B
23. 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.
ANS: B A matter-of-fact approach does not provide the patient with positive reinforcement for self-mutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion.
A 24-year-old patient diagnosed with borderline personality disorder (BPD) is admitted to the inpatient psychiatric unit following a suicide attempt. Which client statements illustrate a primary coping style of persons with BPD? A. "My provider says I might get out of here tomorrow. Do you think I'm ready to go?" B. "Last night the nurse let me go outside and smoke. I can't believe you aren't letting me. I used to think you were the best nurse here." C. "I will never again speak to any of my messed up family members. I know that this will help me to be more functional." D. "I promise I am not feeling suicidal. I won't hurt myself."
ANS: B A primary coping style used by patients with BPD is called splitting. Splitting is the inability to incorporate positive and negative aspects of oneself or others into a whole image. The individual may tend to idealize another person (friend, lover, health care professional) at the start of a new relationship and hope that this person will meet all of his or her needs. At the first disappointment or frustration, however, the individual quickly shifts to devaluation, despising the other person. The other options do not describe splitting, which is a primary coping style of patients with BPD.
8. 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 compliance with treatment. c. Because of increased risk of physical problems with refeeding, the patients permission is needed. d. A team approach to planning the diet ensures that physical and emotional needs will be met.
ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.
1. A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person? a. Victim b. Survivor c. Plaintiff d. Perpetrator
ANS: B A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.
A 28-year-old married client who is seeking treatment after being raped tearfully asks the nurse, "What if I am pregnant?" The nurse's response should be guided by what knowledge? A. The risk of pregnancy after rape is high, up to 50%. B. About 5% of women who are raped become pregnant as a result. C. Reproductive functions shut down during a violent attack, and as a result pregnancy does not occur. D. The client may be worried about how her spouse will accept the baby.
ANS: B About 5% of women who are raped become pregnant as a result (Rape, Abuse & Incest National Network, 2008). Pregnancy prophylaxis can be offered in the emergency department after the results of the pregnancy test are available. The risk of pregnancy is not high after rape. Reproductive functions do not shut down during a violent attack. The patient may be worried about her spouse's reaction; however at this time most important consideration is to give the patient pertinent education regarding rape and pregnancy.
25. Which nursing diagnosis would likely apply both to a patient diagnosed with schizophrenia as well as a patient diagnosed with amphetamine-induced psychosis? a. Powerlessness b. Disturbed thought processes c. Ineffective thermoregulation d. Impaired oral mucous membrane
ANS: B Both types of patients commonly experience paranoid delusions; thus, the nursing diagnosis of Disturbed thought processes is appropriate for both. The incorrect options are not specifically applicable to both.
A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? A. Client will return to a predrug level of functioning within 1 week. B. Client will be medically stabilized while in the hospital. C. Client will state within 3 days that they will totally abstain from drugs and alcohol. D. Client will take a leave of absence from college to alleviate stress.
ANS: B If the patient has been abusing substances heavily, he will begin to experience physical symptoms of withdrawal, which can be dangerous if not treated. The priority outcome is for the patient to withdraw from the substances safely with medical support. Substance use disorder outcome measures include immediate stabilization for individuals experiencing withdrawal such as in this instance, as well as eventual abstinence if individuals are actively using, motivation for treatment and engagement in early abstinence, and pursuit of a recovery lifestyle after discharge. The first option is an unrealistic time frame. It is not likely that the patient will make a total commitment to abstinence within this time frame. Although a leave of absence may be an option, the immediate need is to make sure the patient goes through drug and alcohol withdrawal safely.
You are interviewing Lance, a 31-year-old patient who has been referred to the sexual disorders clinic by his primary care provider. A client describing his problem states, "I can have an orgasm, no problem. It just happens way too soon." This descriptions support what form of sexual dysfunction? A. Erectile disorder B. Premature ejaculation C. Delayed ejaculation D. Male hypoactive sexual desire disorder
ANS: B In premature ejaculation, a man persistently or recurrently achieves orgasm and ejaculation before he wishes to. Erectile disorder (also called erectile dysfunction and impotence) refers to failure to obtain and maintain an erection sufficient for sexual activity. In delayed ejaculation, a man achieves ejaculation during coitus only with great difficulty. Male hypoactive sexual desire disorder is characterized by a deficiency or absence of sexual fantasies or desire for sexual activity.
12. What behavior by a nurse caring for a patient diagnosed with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.
ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.
5. A clinic nurse interviews an adult patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense and then becomes reluctant to provide more information and hurries to leave. How can the nurse best serve the patient? a. Explore the possibility of patient social isolation. b. Have the patient complete an abuse assessment screen. c. Ask whether the patient has ever had psychiatric counseling. d. Ask the patient to disrobe; then assess for signs of physical abuse.
ANS: B In this situation, the nurse should consider the possibility that the patient is a victim of intimate partner violence. Although the patient is reluctant to discuss issues, he or she may be willing to fill out an abuse assessment screen, which would then open the door to discussion.
38. Which question has the highest priority when assessing a newly admitted patient with a history of alcohol abuse? a. "Have you ever had blackouts?" b. "When did you have your last drink?" c. "Has drinking caused you any problems?" d. "When did you decide to seek treatment?"
ANS: B Learning when the patient had the last drink is essential to knowing when to begin to observe for symptoms of withdrawal. The other questions are relevant but of lower priority.
13. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.
ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue. repression, or projection.
A student nurse in the emergency department is assigned to care for a client convicted of the sexual abuse of a child. The student is repulsed by the client because of the nature of his crime and doesn't know how to care for the client under these circumstances. What action should the student nurse take? A. Refuse the assignment because personal feelings will prevent the student from providing good care. B. Talk with a faculty member or an experienced nurse in the emergency department. C. Perform the activities of care but not engage in conversation with the client. D. Suggest to the client that he request a different nurse.
ANS: B Nurses may experience distress when providing care for someone who engages in what they view as objectionable, or even reprehensible, acts. This is sometimes compounded by knowing someone who was a victim or having been victimized ourselves. Talking with a faculty member, a nurse mentor, or someone at a mental health clinic can be helpful and important and may even result in better personal understanding and coping. Refusing an assignment is not an option. Performing the activities of care but not engaging in conversation does not appropriately or fully care for the patient. Telling the patient how she feels would be unprofessional and inappropriate, and is putting the burden of our own feelings onto the patient.
7. A woman tells the nurse, My partner is frustrated with me. I dont have any natural lubrication when we have sex. What type of sexual disorder is evident? a. Genito-Pelvic Pain/Penetration Disorder b. Female Sexual Interest/Arousal Disorder c. Hypoactive Sexual Desire Disorder d. Female Orgasmic Disorder
ANS: B One feature of female sexual interest/arousal disorder relates to inability to maintain physiologic requirements for intercourse. For women, this includes problems with lubrication and swelling. The patients description does not meet criteria for diagnoses in the distracters.
11. 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.
ANS: B One goal of health teaching is normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to eat a large breakfast but no lunch and increase intake after 4 PM will lead to late-day bingeing. Journal entries are private.
17. A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coachs arrest? a. Determine the nature and extent of the coachs sexual disorder. b. Assess the coachs potential for suicide or other self-harm. c. Assess the coachs self-perception of problem and needs. d. Determine whether other children were harmed.
ANS: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patients disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel.
6. A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely? a. "She was very beautiful." b. "I gave her what she wanted." c. "I have issues with my mother." d. "I've been depressed for a long time."
ANS: B Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.
When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? A. It will reduce the need for cognitive therapy. B. It will be prescribed at a higher than typical dose. C. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. D. Long-term management of symptoms is best achieved with tricyclic antidepressants.
ANS: B Research has shown that antidepressant medication together with cognitive-behavioral therapy brings about improvement in bulimic symptoms. Fluoxetine (Prozac), an Selective serotonin reuptake inhibitors (SSRI) antidepressant, has FDA approval for acute and maintenance treatment of bulimia nervosa in adult patients. When fluoxetine is used for bulimia, it is typically at a higher dose than is used for depression. Although no other drugs have FDA approval for this disorder, tricyclic antidepressants helped reduce binge eating and vomiting over short terms.
26. Which common assessment finding would be most applicable to a patient diagnosed with any personality disorder? The patient: a. demonstrates behaviors that cause distress to self rather than to others. b. has self-esteem issues, despite his or her outward presentation. c. usually becomes psychotic when exposed to stress. d. does not experience real distress from symptoms.
ANS: B Self-esteem issues are present, despite patterns of withdrawal, grandiosity, suspiciousness, or unconcern. They seem to relate to early life experiences and are reinforced through unsuccessful experiences in loving and working. Personality disorders involve lifelong, inflexible, dysfunctional, and deviant patterns of behavior that cause distress to others and, in some cases, to self. Patients with personality disorders may experience very real anxiety and distress when stress levels rise. Some individuals with personality disorders, but not all, may decompensate and show psychotic behaviors under stress.
10. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? a. Defensive coping b. Sexual dysfunction c. Ineffective sexuality pattern d. Disturbed sensory perception, tactile
ANS: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping.
The mother of a 4-year-old daughter states that the child has recently begun, "Touching her vagina and rubs herself down there all the time." The child drew a picture showing two people with one on top of the other and said they were "doing sex." Based on the assessment description, what conclusion should the nurse explore further? A. Educate the mother to normal developmental behavior in a 4-year-old child. B. There is a possibility that the child has been sexually abused. C. The mother should be enrolled in parenting classes to improve her parenting skills. D. The child's exposure to graphic sexual images on television should be monitored closely.
ANS: B Sexualized behavior is one of the most common symptoms of sexual abuse in children. Younger children may draw sexually explicit images, demonstrate sexual aggression, or act out sexual interactions in play, for example, with dolls. Masturbation may be excessive in sexually abused children. It is not normal developmental behavior for a 4-year-old child. The other options may be true, but sexual abuse is more likely and must be investigated.
A 16-year-old patient being treated for anorexia, has been prescribed medication to reduce compulsive behaviors regarding food now that ideal weight has been reached. Which class of medication is prescribed for this specific issue associated with eating disorders? A. Mood stabilizers B. Antidepressants C. Anxiolytics D. Atypical antipsychotics
ANS: B The antidepressant fluoxetine (Prozac, an SSRI) has proven useful in reducing obsessive-compulsive behavior after the patient has reached a maintenance weight. Anxiolytics would be prescribed for anxiety. Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviors and resistance to weight gain. Mood stabilizers are not specifically used in treatment of eating disorders.
1. A new staff nurse tells the clinical nurse specialist, I am unsure about my role when patients bring up sexual problems. The clinical nurse specialist should give clarification by saying, All nurses: a. qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples.
ANS: B The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors. Additional education is necessary. A registered nurse may provide basic information about sexual function, but complex questions may require referral.
17. A survivor in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.
ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.
19. A nurse in the emergency department tells an adult, "Your mother had a severe stroke." The adult tearfully says, "Who will take care of me now? My mother always told me what to do, what to wear, and what to eat. I need someone to reassure me when I get anxious." Which term best describes this behavior? a. Histrionic b. Dependent c. Narcissistic d. Borderline
ANS: B The main characteristic of the dependent personality is a pervasive need to be taken care of that leads to submissive behaviors and a fear of separation. Histrionic behavior is characterized by flamboyance, attention seeking, and seductiveness. Narcissistic behavior is characterized by grandiosity and exploitive behavior. Patients with borderline personality disorder demonstrate separation anxiety, impulsivity, and splitting.
22. A nurse worked at a hospital for several months, resigned, and then took a position at another hospital. In the new position, the nurse often volunteers to be the medication nurse. After several serious medication errors, an investigation reveals that the nurse was diverting patient narcotics for self-use. What early indicator of the nurse's drug use was evident? a. Accepting responsibility for medication errors. b. Seeking to be assigned as a medication nurse. c. Frequent complaints of physical pain. d. High sociability with peers.
ANS: B The nurse intent on diverting drugs for personal use often attempts to isolate him- or herself from peers rather than being sociable. The person seeks access to medications. Usually, the person will blame errors on others rather than accepting responsibility.
7. 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 patients feelings. d. Help the patient balance energy expenditures with caloric intake.
ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety, as well as communicating empathy, relate to coping. Helping the patient achieve balance between energy expenditure and caloric intake is an inappropriate intervention.
14. A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This patient said, Ive 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 commitment.
ANS: B The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the patient is in the emergency department. Facilitating the abusers counseling may require weeks or months.
24. 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.
ANS: B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis.
27. An adult in the emergency department states, Everything I see appears to be waving. I am outside my body looking at myself. I think Im 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.
ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going crazy. Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.
9. A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of: a. Paraphilic Disorder. b. Female Orgasmic Disorder. c. Genito-Pelvic Pain/Penetration Disorder. d. Female Sexual Interest/Arousal Disorder.
ANS: B The persistent inhibition of orgasm is a form of sexual dysfunction called female orgasmic disorder. Genito-pelvic pain/penetration disorder applies to painful intercourse. The patient has not indicated that her interest in sexual activity is diminished, so female sexual interest/arousal disorderdoes not apply. Paraphilic disorder is not applicable.
16. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Anger phase b. Acute phase c. Outward adjustment phase d. Long-term reorganization phase
ANS: B The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.
A 26-year-old patient who abuses heroin states to you, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? A. Intoxication B. Tolerance C. Withdrawal D. Addiction
ANS: B Tolerance is described as needing increasing greater amounts of a substance to receive the desired result to become intoxicated or finding that using the same amount over time results in a much-diminished effect. Intoxication is the effect of the drug. Withdrawal is a set of symptoms patients experience when they stop taking the drug. Addiction is loss of behavioral control with craving and inability to abstain, loss of emotional regulation, and loss of the ability to identify problematic behaviors and relationships.
1. A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we can't afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.
ANS: B child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.
3. The nursing diagnosis ineffective denial is especially useful when working with substance use disorders and gambling. Which statements describe this diagnosis? Select all that apply. a. Reports inability to cope b. Does not perceive danger of substance use or gambling c. Minimizes symptoms d. Refuses healthcare attention e. Unable to admit impact of disease on life pattern
ANS: B, C, D, E
4. After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined
ANS: B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. "Reported" should be used instead of "alleged." "Penetration" should be used instead of "intercourse." "Declined" should be used instead of "refused."
1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) 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.
ANS: B, C, F The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.
3. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis
ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.
10. Donald, a 49-year-old male, is admitted for inpatient alcohol detoxification. He is cachexic, has multiple scabs on his arms and legs, and has lower extremity edema. An appropriate nursing diagnosis for Donald along with an expected outcome is: a. Risk for injury/Remains free from injury b. Ineffective denial/Accepts responsibility for behavior c. Nutrition: Less than body requirements/Maintains nutrient intake for metabolic needs d. Risk for suicide/Expresses feelings, plans for the future
ANS: C
10. Malika agrees to try losing weight according to the nurse practitioner's outlined plan. Additional teaching is warranted when Malika states: a. "I am willing to admit I am depressed." b. "Psychotherapy will be a part of my treatment." c. "I prefer to have a gastric bypass rather than use this plan." d. "My comorbid conditions may improve with weight loss."
ANS: C
2. The nurse should plan to educate the male patients prescribed a statin medication on the possible development of which commonly observed side effect? a. Impotence b. Gynecomastia c. Decreased libido d. Delayed ejaculation
ANS: C
7. A young woman named Carly was raped behind the restaurant where she works after closing shift. Six months have passed and Carly has not been able to return to work, refuses to go out to eat, and feels that she has less value as a woman now that she has been raped. Carly's clinical presentation suggests: a. Re-experiencing b. Hyperarousal c. Avoidance d. Physical effects
ANS: C
7. Opioid use disorder is characterized by: a. Lack of withdrawal symptoms b. Intoxication symptoms of pupillary dilation, agitation, and insomnia c. Tolerance d. Requiring smaller amounts of the drug to achieve a high over time
ANS: C
7. When Melissa was a small child, she insisted that she was a boy, refused to wear dresses, and wanted to be called Mitch. As Melissa reached puberty, she no longer displayed a desire to be male. This change in identity is considered: a. Gender dysphoria b. Reaction formation c. Normal d. Early transgender syndrome
ANS: C
8. Phillip, a 63-year-old male, has exposed his genitals in public for all of his adult life, but the act has lost some of the former thrill. A rationale for this change in his experience may be: a. An increasing sense of shame b. Disgust over his lack of control c. Desire waning with age d. Progression into actual assault
ANS: C
8. Ron is a victim of assault and has revealed to his family and friends the fact that he was raped. The family reacts with horror and disgust, and the nurse caring for Ron recognizes: a. Ron's family is being judgmental. b. Ron's family should leave the hospital. c. Ron's family will also need support. d. Dysfunctional family dynamics.
ANS: C
9. Garret's wife of 8 years is divorcing him because the marriage never developed a warm or loving atmosphere. Garrett states in therapy, "I have always been a loner," and was never concerned about what others think. The nurse practitioner suggests that Garrett try a trial of bupropion (Wellbutrin) to: a. Improve his flat emotions b. Assist in getting a good night's sleep c. Increase the pleasure of living d. Prepare Garrett for group therapy
ANS: C
9. Perpetrators of sexual assault are often incarcerated but frequently do not undergo therapy. Samuel, convicted of rape and sentenced to 15 years in prison, has requested to see a therapist. The psychiatric nurse practitioner is surprised to learn of the request as many perpetrators: a. Boast of their assault history b. Feel regret and remorse c. Do not acknowledge the need for change d. Are unable to recognize rape as a crime
ANS: C
3. 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?
ANS: C Although all the questions might be appropriate to ask, only What do you eat in a typical day? focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patients thoughts on present weight explores the patients feelings about weight.
Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? A. "I purge only once a day now instead of twice." B. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." C. "I am a hard worker and I am very compassionate toward others." D. "I always purge when I'm alone so that I'm not a bad role model for my younger sister."
ANS: C An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.
35. A patient is admitted in a comatose state after ingesting 30 capsules of pentobarbital sodium. A friend of the patient says, "Often my friend drinks, along with taking more of the drug than is prescribed." What is the effect of the use of alcohol with this drug? a. The drug's metabolism is stimulated. b. The drug's effect is diminished. c. A synergistic effect occurs. d. There is no effect.
ANS: C Both pentobarbital and alcohol are CNS depressants and have synergistic effects. Taken together, the action of each would potentiate the other.
30. A newly hospitalized patient has needle tracks on both arms. A friend states that the patient uses heroin daily but has not used in the past 24 hours. The nurse should assess the patient for: a. slurred speech, excessive drowsiness, and bradycardia. b. paranoid delusions, tactile hallucinations, and panic. c. runny nose, yawning, insomnia, and chills. d. anxiety, agitation, and aggression.
ANS: C Early signs and symptoms of narcotic withdrawal resemble symptoms of onset of a flulike illness, but without temperature elevation. The incorrect options reflect signs of intoxication or CNS depressant overdose and CNS stimulant or hallucinogen use.
19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. maintaining patients concentration and attention. b. shifting the patients focus from food to psychotherapy. c. promoting processing of anxiety associated with eating. d. focusing on weight control mechanisms and food preparation.
ANS: C Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients concentration and attention is important, but not the primary purpose of the schedule.
Which statement, made by a female adult concerning her boyfriend, should cause the nurse to suspect that the client is at risk for being emotionally abused? A. "He has a good job and keeps control of all the finances but our electricity still got turned off last week." B. "I didn't tell him I was coming because he is under so much stress at work I didn't want to add to it." C. "He yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." D. "He has always had a fiery temper."
ANS: C Emotional abuse may be less obvious and more difficult to assess than physical violence, but it can be identified through indicators such as low self-esteem, reported feelings of inadequacy, and anxiety. Controlling the finances and having the electricity turned off describes the possibility of economic abuse. Not wanting to add to the boyfriend's stress does not describe an abusive situation. Describing the boyfriend as having a temper would more likely hint at physical abuse rather than emotional.
27. A 5-year-old child was diagnosed with encopresis. Which assessment finding would the nurse expect associated with this diagnosis? The child: a. frequently smears feces on clothing and toys. b. experiences frequent nocturnal episodes of bedwetting. c. has accidents of defecation at kindergarten three times a week. d. has occasional episodes of voiding accidents at the day care center.
ANS: C Encopresis refers to unsuccessful bowel control. Bowel control is expected by age 5, so frequent involuntary defecation is associated with this diagnosis. Smearing feces is behavioral. Enuresis refers to the voiding of urine during the day (diurnal) or at night (nocturnal).
11. An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? a. No complaints related to sexual function; to return next week. b. Patient reports achieving orgasm last week; seems very happy. c. Reports satisfaction with sexual encounters; feels partner is supportive. d. Reports achieving orgasm occasionally; relationship with partner is adequate.
ANS: C Human sexuality, sexual expression, and expectations related to sexuality vary tremendously from person to person and across cultures. Therefore, the best indication of satisfactory treatment is that the patient is satisfied with what has been achieved. In this instance, Patient reports satisfaction with sexual encounters; feels partner is supportive best indicates that the patient is satisfied, and both presenting issues are progressing in a positive manner. Achieving orgasm once or occasionally may or may not represent satisfactory progress to the patient. No complaints does not necessarily mean that satisfaction exists.
16. A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. 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.
ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiological integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the dangers associated with hypokalemia.
8. Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.
ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.
25. 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. c. substance addiction. b. substance abuse. d. substance intoxication.
ANS: C Nicotine meets the criteria for a substance, the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.
11. An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question? a. "Do you drink excessively?" b. "Did your partner beat you?" c. "How did this happen to you?" d. "What did you do to deserve this?"
ANS: C Obtaining the person's explanation is necessary. If the explanation does not match the injuries or if the victim minimizes the injuries, abuse should be suspected.
1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified
ANS: C Overly controlled eating behaviors, extreme weight loss, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with eating disorder not otherwise specified may be obese.
12. Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? a. Homosexual b. Ritualistic behaviors c. Seeks access to children d. Self-confident professional
ANS: C Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder.
The nurse feels uncomfortable talking with a young male client about his sexual problem. Which action should the nurse take? A. Ask another nurse to take over the interview so you don't project your feelings onto the patient. B. Pause the interview and take time to gather your thoughts and do positive self-talk. C. Continue the interview using an appropriate professional tone and matter-of-fact approach. D. Ask Lance whether he would feel more comfortable speaking with a physician about his problem.
ANS: C Remembering your position as a professional and addressing the topics in a tone and manner appropriate of a professional will increase your comfort, along with the patient's. The response in the first option would be confusing to the patient and does not address your feelings or work to resolve them. Pausing the interview would not be appropriate because self-assessment is best done before patient interaction. Asking the patient whether he would feel more comfortable speaking with a physician projects your feelings of being uncomfortable onto the patient and does not carry out your professional role and responsibility.
19. A patients medical record documents sexual masochism. This patient derives sexual pleasure: a. from inanimate objects. b. by inflicting pain on a partner. c. when sexually humiliated by a partner. d. from touching a non-consenting person.
ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.
According to current theory, which statement regarding eating disorders is accurate? A. Eating disorders are psychotic disorders in which patients experience body dysmorphic disorder. B. Eating disorders are frequently misdiagnosed. C. Eating disorders are possibly influenced by sociocultural factors. D. Eating disorders are rarely comorbid with other mental health disorders.
ANS: C The Western cultural ideal that equates feminine beauty with tall, thin models has received much attention in the media as a cause of eating disorders. Studies have shown that culture influences the development of self-concept and satisfaction with body size. Eating disorders are not psychotic disorders. There is no evidence that eating disorders are frequently misdiagnosed. Comorbidity for patients with eating disorders is more likely than not. Personality disorders, affective disorders, and anxiety frequently occur with eating disorders.
It has been 6 months since a woman was raped. Which statement by the client would indicate that counseling has helped her to achieve an important long-term outcome? A. "I'm not having as many nightmares about the rape so I do get a little sleep at night." B. "My husband has been very supportive during this whole thing." C. "I am not going to let that rapist be in control of my life. I know things will keep getting better." D. "I am not pressing charges because I want this whole thing to be over with so I can move on."
ANS: C The correct option expresses empowerment and hope for the future. Long-term outcome includes the absence of any residual symptoms after the trauma and would be indicated by healing of physical injuries, relief of anger in nondestructive ways, comfort in relationships, and feelings of empowerment and expression of hope. While there has been an improvement, having nightmares and not sleeping well indicates that the patient is still going through acute stress related to the rape. The fact that the husband is supportive is a positive statement regarding her husband but doesn't express her own indicators of recovery. Not pressing charges may indicate that the patient may not be dealing with the event in a healthy way by avoiding the trauma.
17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patients body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor
ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.
22. When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.
ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.
Which statement is true regarding substance addiction and medical comorbidity? A. Most substance abusers do not have medical comorbidities. B. There has been little research done regarding substance addiction disorders and medical comorbidity. C. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. D. Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier.
ANS: C The more common co-occurring medical conditions are hepatitis C, diabetes, cardiovascular disease, HIV infection, and pulmonary disorders. The high comorbidity appears to be the result of shared risk factors, high symptom burden, physiological response to licit and illicit drugs, and the complications from the route of administration of substances. Most substance abusers do have medical comorbidities. There is research such as the 2001-2003 National Comorbidity Survey Replication (NCS-R) showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction in that they cause added symptoms, stress, and burden.
Which statement best illustrates support in giving care to a patient who has just been sexually assaulted? A. "I'm so sorry for what you have been through." B. "Don't worry. It's hard now, but everything will be alright." C. "I am going to stay with you. We can talk as long as you want to." D. "Let's talk about new coping skills you can use."
ANS: C The most effective approach for counseling in the emergency department or crisis center is to provide nonjudgmental care and optimal emotional support. Sympathy is not a therapeutic response and does not focus on the patient. Telling the patient not to worry is false reassurance. It is too soon to try to learn new coping skills because the patient is in an acute stress phase.
31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurses 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.
ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of ones own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.
19. A patient who was admitted for a heroin overdose received naloxone (Narcan), which improved the breathing pattern. Two hours later, the patient reports muscle aches, abdominal cramps, gooseflesh and says, "I feel terrible." Which analysis is correct? a. The patient is exhibiting a prodromal symptom of seizures. b. An idiosyncratic reaction to naloxone is occurring. c. Symptoms of opiate withdrawal are present. d. The patient is experiencing a relapse.
ANS: C The symptoms given in the question are consistent with narcotic withdrawal and result from administration of naloxone. Early symptoms of narcotic withdrawal are flulike in nature. Seizures are more commonly observed in alcohol withdrawal syndrome.
Which statement provides accurate information regarding transvestic disorder? A. Most people with this disorder are homosexual. B. Only men are diagnosed with transvestic disorder. C. Sexual orientation has no bearing on transvestic disorder. D. Transvestic behavior develops in middle adulthood.
ANS: C Unlike in gender dysphorias, in transvestic disorder there are no sexual orientation issues, and people with transvestic disorder do not desire a sex change. Transvestites are usually heterosexual. Although more common in men, women are also diagnosed with transvestic disorder. Transvestic disorder usually develops early in life.
4. A new patient beginning an alcoholism rehabilitation program says, Im 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. Select the nurses most therapeutic responses. 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.
ANS: C, D The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.
2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression
ANS: C, D, E Priority milieu interventions support restoration of weight and normalization of eating patterns. This requires close supervision of the patients eating and prevention of exercise, purging, and other activities. There is strict adherence to menus. Observe patients during and after meals to prevent throwing away food or purging. Monitor all trips to the bathroom. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.
1. Which patient statement suggests a concern over one's ability to perform sexually? a. "My partner and I aren't as close as we once were." b. "I'm not as desirable as I once was." c. "My personal life has changed a lot." d. "I'm not the partner I used to be."
ANS: D
2. Considering the guilt that women feel after being sexually assaulted, which nursing assessment question has priority? a. "Do you want the police to be called?" b. "Did you recognize the person who assaulted you?" c. "Do you have someone you trust that can stay with you?" d. "Do you have any thoughts about harming yourself?"
ANS: D
2. When assessing a patient diagnosed with a borderline personality disorder, which statement by the patient warrants immediate attention? a. "My mother died ten years ago." b. "I haven't needed medication in weeks." c. "My dad never loved me." d. "I'd really like to hurt her for hurting me."
ANS: D
4. What action should you take when a female staff member is demonstrating behaviors associated with a substance use disorder? a. Accompany the staff member when she is giving patient care. b. Offer to attend rehabilitation counseling with her. c. Refer her to a peer assistance program. d. Confront her about your concerns and/or report your concerns to a supervisor immediately.
ANS: D
4. What safety-related responsibility does the nurse have in any situation of suspected of abuse? a. Protect the patient from future abuse by the abuser. b. Inform the suspected abuser that the authorities have been notified. c. Arrange for counseling for all involved parties but especially the patient. d. Report suspected abuse to the proper authorities.
ANS: D
4. Which intervention will promote independence in a patient being treated for bulimia nervosa? a. Have the patient monitor daily caloric intake and intake and output of fluids. b. Encourage the patient to use behavior modification techniques to promote weight gain behaviors. c. Ask the patient to use a daily log to record feelings and circumstances related to urges to purge. d. Allow the patient to make limited choices about eating and exercise as weight gain progresses.
ANS: D
5. Obtaining a sexual history can be embarrassing for the patient and practitioner. Experience with addressing the topic can help, as well as: a. Using informal language familiar to the patient's age b. Avoiding specifics and keeping the interview on general topics c. Avoiding eye contact d. Using a professional tone of voice and a relaxed posture
ANS: D
6. The stress of being raped often results in suffering similar to people who have witnessed a murder or had a physiological reaction to trauma, resulting in: a. Posttraumatic stress disorder b. Anxiety c. Depression d. All of the above
ANS: D
7. Larry is from a small town and began displaying aggressive and manipulative traits while still a teenager. Now at 40 years old, Larry is serving a life sentence for the murders of his wife and her brother. John, the prison psychiatric nurse practitioner, recognizes that Larry's treatment will most likely: a. Transform Larry to a model prisoner b. Not improve Larry's coping skills c. Reaffirm Larry's high-risk behaviors d. Manifest as small incremental changes
ANS: D
9. 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.
ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.
4. Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should: a. develop an understanding of human sexual response. b. assess the patients sexual functioning and needs. c. acquire knowledge of the patients sexual roles. d. clarify own personal values about sexuality.
ANS: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care.
2. 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
ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This is a subjective consideration. The other indicators are more objective but less related to the nursing diagnosis.
4. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial
ANS: D Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.
22. 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.
ANS: D Fear of abandonment is a central theme for most patients with borderline personality disorder. This fear is often exacerbated when patients with borderline personality disorder experience success or growth.
2. A woman in the last trimester of pregnancy drinks 8 to 12 ounces of alcohol daily. The nurse plans for the delivery of an infant who is: a. jaundiced. b. dependent on alcohol. c. healthy but underweight. d. microcephalic and cognitively impaired.
ANS: D Fetal alcohol syndrome is the result of alcohol's inhibiting fetal development in the first trimester. The fetus of a woman who drinks that much alcohol will probably have this disorder. Alcohol use during pregnancy is not likely to produce the findings listed in the distractors.
34. When assessing a patient who has ingested flunitrazepam (Rohypnol), the nurse would expect: a. acrophobia. b. hypothermia. c. hallucinations. d. anterograde amnesia.
ANS: D Flunitrazepam is known as the date rape drug. It produces disinhibition and a relaxation of voluntary muscles, as well as anterograde amnesia for events that occur. The other options do not reflect symptoms commonly observed after use of this drug.
26. 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
ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use.
41. Which assessment findings support a nurse's suspicion that a patient has been using inhalants? a. Pinpoint pupils and respiratory rate of 12 breaths per minute b. Perforated nasal septum and hypertension c. Drowsiness, euphoria, and constipation d. Confusion, mouth ulcers, and ataxia
ANS: D Inhalants are usually CNS depressants, giving rise to confusion and ataxia. Mouth ulcers come from the irritation of buccal mucosa by the inhalant. The incorrect options relate to cocaine snorting and opioid abuse.
6. While performing an assessment, the nurse says to a patient, While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now? The purpose of this question is to: a. identify areas of sexual dysfunction for treatment. b. determine possible homosexual urges. c. introduce the topic of masturbation. d. identify sexual misinformation.
ANS: D Misinformation about normal sex and sexuality is common. Lack of knowledge may affect an individuals sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.
13. A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol) by an assailant. Which intervention has priority? Monitoring for: a. coma. c. hypotonia. b. seizures. d. respiratory depression.
ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma.
A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? A. "It helps your mood so that you don't feel the need to do drugs." B. "It will keep you from experiencing flashbacks." C. "It is a sedative that will help you sleep at night so you are more alert and able to make good decisions." D. "It helps prevent relapse by reducing drug cravings."
ANS: D Naltrexone is used for withdrawal and also to prevent relapse by reducing the craving for the drug. None of the other options do not accurately describe the action of naltrexone.
36. Which medication is the nurse most likely to see prescribed as part of the treatment plan for both a patient in an alcoholism treatment program and a patient in a program for the treatment of opioid addiction? a. methadone (Dolophine) b. bromocriptine (Parlodel) c. disulfiram (Antabuse) d. naltrexone (Revia)
ANS: D Naltrexone is useful for treating both opioid and alcohol addictions. As an opioid antagonist, it blocks the action of opioids. Because it blocks the mechanism of reinforcement, it also reduces or eliminates alcohol craving.
16. A patient comes to an outpatient appointment obviously intoxicated. The nurse should: a. explore the patient's reasons for drinking today. b. arrange admission to an inpatient psychiatric unit. c. coordinate emergency admission to a detoxification unit. d. tell the patient, "We cannot see you today because you've been drinking."
ANS: D One cannot conduct meaningful therapy with an intoxicated patient. The patient should be taken home to recover and then make another appointment. Hospitalization is not necessary.
6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. weigh self accurately using balanced scales. b. limit exercise to less than 2 hours daily. c. select clothing that fits properly. d. gain 1 to 2 pounds.
ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome would not be on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.
16. Which statement about paraphilic disorders is accurate? a. Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. b. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts. c. Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. d. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon.
ANS: D Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behaviors associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males in early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to the stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.
31. A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled "pentobarbital sodium." What is the nurse's first action? a. Test reflexes b. Check pupils c. Initiate vomiting d. Establish a patent airway
ANS: D Pentobarbital sodium is a barbiturate. Maintaining a patent airway is the priority when the patient is unconscious. Assessing neurologic function by testing reflexes and checking pupils can wait. Vomiting should not be induced when a patient is unconscious because of the danger of aspiration.
11. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others
ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.
1. 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 should get the money. These statements show: a. shame. c. superficial remorse. b. suspiciousness. d. lack of guilt feelings.
ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patients remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.
26. Which is an important nursing intervention when giving care to a patient withdrawing from a central nervous system (CNS) stimulant? a. Make physical contact by frequently touching the patient. b. Offer intellectual activities requiring concentration. c. Avoid manipulation by denying the patient's requests. d. Observe for depression and suicidal ideation.
ANS: D Rebound depression occurs with the withdrawal from CNS stimulants, probably related to neurotransmitter depletion. Touch may be misinterpreted if the patient is experiencing paranoid tendencies. Concentration is impaired during withdrawal. Denying requests is inappropriate; maintaining established limits will suffice.
9. 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
ANS: D Refeeding resulting in too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment is a necessity to ensure the patients physiological integrity. The other body systems are not initially involved in the refeeding syndrome.
22. A patient 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
ANS: D Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.
29. 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.
ANS: D Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.
Which of the following statements by a woman who was sexually assaulted a year ago would indicate that she has recovered from the trauma? A. "I don't walk home alone anymore because I am terrified it may happen again." B. "I am sleeping better but still only get about 5 hours of sleep at night because of bad dreams about the rape." C. "I realize that I was partly to blame for the rape because of walking in an unsafe neighborhood." D. "My husband and I are having sex again and I enjoy it."
ANS: D Sexual assault survivors are considered to be recovered if they are relatively free of any signs or symptoms of acute stress disorder and posttraumatic stress disorder. Signs of recovery include sleeping well with few instances of nightmares or dreams, being only mildly fearful, having positive self-regard, and returning to prerape sexual functioning and interest. The closer the survivor's lifestyle is to how it was before the rape, the more complete the recovery has been. Not walking home because of being terrified indicates a high level of fear. Only sleeping 5 hours at night indicates sleeping is still seriously disturbed. Stating that she is partly to blame indicates that the patient is placing the blame for the rape on herself instead of the perpetrator.
22. Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? a. Urine output 40 mL/hr b. Pulse rate 58 beats/min c. Serum potassium 3.4 mEq/L d. Systolic blood pressure 62 mm Hg
ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 mL/hr. A potassium level of 3.4 mEq/L is within the normal range.
12. A new patient in an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening." Which response by the nurse will help the patient view the drinking more honestly? a. "I see," and use interested silence. b. "I think you may be drinking more than you report." c. "Being a social drinker involves having a drink or two once or twice a week." d. "You describe drinking steadily throughout the day and evening. Am I correct?"
ANS: D The answer summarizes and validates what the patient reported but is accepting rather than strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in treatment.
10. 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 doesnt seem to solve your problems. You are thin now but still unhappy.
ANS: D The correct response is the only strategy that attempts to question the patients distorted thinking.
A 37-year-old patient, referred to the mental health clinic with a suspected personality disorder, is withdrawn and suspicious and states, "I've always preferred to be alone" and then adds, "I can read your thoughts whenever I want to." This presentation supports which psychiatric diagnosis? A. Obsessive-compulsive personality disorder B. Narcissistic personality disorder C. Avoidant personality disorder D. Schizotypal personality disorder (STPD)
ANS: D The main traits that describe STPD are psychoticism such as eccentricity, odd or unusual beliefs and thought processes, and social detachment by preferring to be socially isolated, as well as being overly suspicious or anxious. In obsessive-compulsive personality disorder the main pathological personality traits are rigidity and inflexible standards of self and others, along with persistence of goals long after they are necessary, even if they are self-defeating or negatively affect relationships. People with narcissistic personality disorder come across as arrogant, with an inflated view of their self-importance. They have a need for constant admiration, along with a lack of empathy for others, a factor that strains most relationships over time. Traits of avoidant personality disorder include low self-esteem, feelings of inferiority compared with peers, and a reluctance to engage in unfamiliar activities involving new people.
13. 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.
ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.
24. Which nursing diagnosis is more 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
ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.
5. A patient 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
ANS: D The patients history and lab result support the nursing diagnosis Imbalanced nutrition: less than body requirements. Data are not present that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.
18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, I wont 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 body requirements related to self-starvation
ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patients self-starvation is the priority.
29. 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
ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.
What is the priority outcome for a toddler who has been sexually abused? A. The mother will learn coping techniques to support the child. B. The child will be able to verbalize exactly what happened to her. C. The child will no longer demonstrate inappropriate sexual behavior. D. The sexual abuse will cease immediately.
ANS: D The sexual abuse will cease immediately. The highest priority in this case is that the abuse stops so that the patient can be safe and undergo recovery. The question is asked about the priority outcome for the victim, not the mother. Verbalizing exactly what happened is not a priority. The victim will most likely stop the sexualized behavior when the abuse has stopped and recovery is supported by age-appropriate interventions.
5. A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, Without the red teddies, I am not interested in sex. The nurse can assess this as consistent with: a. exhibitionism. b. voyeurism. c. frotteurism. d. fetishism.
ANS: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously.Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations.
A client, prescribed which class of antidepressantive medication should be monitored for the development of premature ejaculation? A. Monoamine oxidase (MAO) inhibitors B. Tricyclic antidepressants C. Atypical antipsychotics D. selective serotonin reuptake inhibitor (SSRI) antidepressants
ANS: D Treatments include antidepressants in the SSRI category. Conversely, pharmacotherapy may cause erectile dysfunction, and medications may need to be evaluated for change or dose reduction. The other options are not used for premature ejaculation.
8. The male manager of a health club placed a hidden video camera in the womens locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is: a. homosexuality. b. exhibitionism. c. pedophilia. d. voyeurism.
ANS: D Voyeurism is achieving sexual pleasure through the viewing of others in intimate situations, such as undressing, bathing, or having sexual relations. A homosexual individual would be interested in watching members of the same sex, and homosexuality is not typically associated with voyeurism. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with children.
3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply) a. administration of naloxone (Narcan). b. vitamin B12 and folate supplements. c. restoring nutritional integrity. d. management of heart rate. e. environmental safety.
ANS: D, E Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.
3. While caring for a patient with a methamphetamine overdose, which tasks are the priorities of care? Select all that apply. a. Administration of naloxone (Narcan) b. Vitamin B12 and folate supplements c. Restoring nutritional integrity d. Prevention of seizures e. Reduction of fever
ANS: D, E Hyperpyrexia and convulsions are common when a patient has overdosed on a CNS stimulant. These problems are life threatening and take priority. Naloxone (Narcan) is administered for opiate overdoses. Vitamin B12 and folate may be helpful for overdoses from solvents, gases, or nitrates. Nutrition is not a priority in an overdose situation.
5. 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 patients vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patients personal effects
ANS: B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.
20. 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 womens shelter d. Vocational counseling
ANS: C Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.
7. 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.
ANS: A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.
11. A patient tells the nurse, My husband lost his job. Hes 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
ANS: A An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.
16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging
ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a bad trip.
18. 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. c. role reversal. b. assertiveness. d. homeostasis.
ANS: A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario.
13. 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 spouses behavior carefully. d. It is good that you are supportive of your spouses sobriety and want to help maintain it.
ANS: A During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.
2. 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.
ANS: A Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.
11. A patient admitted to an alcoholism rehabilitation program tells the nurse, Im 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
ANS: A Minimizing ones drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for ones faults or problems. Rationalization involves making excuses. Introjection involves incorporating a quality of another person or group into ones own personality.
21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a schizotypal personality disorder? a. Respect the patients need for periods of social isolation. b. Prevent the patient from violating the nurses rights. c. Teach the patient how to select clothing for outings. d. Engage the patient in community activities.
ANS: A Patients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the patient to match clothing is not the priority intervention. Patients with schizotypal personality disorder rarely engage in behaviors that violate the nurses rights or exploit the nurse.
13. After treatment for a detached retina, a survivor of intimate partner abuse says, My partner only abuses me when I make mistakes. Ive considered leaving, but I was brought up to believe you stay together, no matter what happens. Which diagnosis should be the focus of the nurses 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
ANS: A Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the patients safety.
15. A patient diagnosed with borderline personality disorder was hospitalized several times after self-mutilating episodes. The patient remains impulsive. Which nursing diagnosis is the initial focus of this therapy? a. Risk for self-directed violence b. Impaired skin integrity c. Risk for injury d. Powerlessness
ANS: A Risk for self-mutilation is a nursing diagnosis relating to patient safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the patient with borderline personality disorder.
5. 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. c. have eating disorders. b. are attention seeking. d. are developmentally delayed.
ANS: A Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.
15. 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
ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.
1. 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. Im 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.
ANS: A The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the patient feel accepted.
17. 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
ANS: A The patient is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this patient; however, the risk for injury is a higher priority.
14. A patient says, I get in trouble sometimes because I make quick decisions and act on them. Select the nurses most therapeutic response. a. Lets consider the advantages of being able to stop and think before acting. b. It sounds as though youve developed some insight into your situation. c. I bet you have some interesting stories to share about overreacting. d. Its good that youre showing readiness for behavioral change.
ANS: A The patient is showing openness to learning techniques for impulse control. One technique is to teach the patient to stop and think before acting impulsively. The patient can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.
19. 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.
ANS: A The patient will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.
19. 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 cant face my friends. There is no reason to go on. Select the nurses 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.
ANS: A The patients words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.
12. A nurse works a 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.
ANS: A The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Counseling is not the focus until immediate problems are resolved. The victim remains anonymous. The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.
16. A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, I cant believe Ive 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
ANS: A The victims response is typical of the acute phase and shows cognitive, affective, and behavioral disruptions. This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization) phase, anger, or a delayed reaction.
17. 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.
ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.
9. 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
ANS: A Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When patients with antisocial personality disorders use denial, they use it effectively.
3. 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. Its 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.
ANS: A, B, C An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.
1. A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, My father doesnt 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
ANS: A, B, C Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wifes admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.
3. 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
ANS: A, B, C Body maps, DNA swabs, and photographs are used to collect and preserve body fluids and other forensic evidence.
2. 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 patients family members to the examination room. e. Put an arm around the patient to demonstrate support and compassion.
ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victims anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patients privacy may be compromised by family presence.
1. When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, 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
ANS: A, C, D These reactions are common to the long-term phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes would not be expected.
4. 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 patients previous sexual experiences c. The patients history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patients support system
ANS: A, D, E The nurse assesses the victims level of anxiety, coping mechanisms, available support systems, signs and symptoms of emotional trauma, and signs and symptoms of physical trauma. The history of STDs or previous sexual experiences has little relevance.
10. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior 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.
ANS: B A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patients body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.
1. A patient diagnosed with alcoholism asks, How will Alcoholics Anonymous (AA) help me? Select the nurses 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.
ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.
9. A patient asks for information about Alcoholics Anonymous. Select the nurses best response. Alcoholics Anonymous 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.
ANS: B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.
14. Which situation describes consensual sex rather than rape? a. A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects. b. A womans 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.
ANS: B Only the key describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are of legal age.
17. 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 persons 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.
ANS: B All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.
18. An unconscious teenager is treated in the emergency department. The teenagers friends suspect a rape occurred at a party. Priority action by the nurse should focus on: a. preserving rape evidence. b. maintaining physiologic stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.
ANS: B Because the patient is unconscious, the risk for airway obstruction is present. The nurses priority will focus on maintaining physiologic stability. The distracters are of lower priority than preserving physiological functioning.
2. 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/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurses priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.
ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.
11. 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?
ANS: B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. Why questions represent probing, which is a non-therapeutic communication technique. The victim may or may not have friends who have had this experience, but its important to talk about his feelings rather than theirs.
3. 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
ANS: B Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.
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
ANS: B Maintaining consistent limits is by far the most difficult intervention because of the patients superior skills at manipulation. Supporting behavioral change and monitoring patient safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques.
7. 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. Serotonin norepinephrine reuptake inhibitor (SNRI)
ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.
16. An older adult with Alzheimers disease lives with family in a rural area. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Multiple caregivers b. Alzheimers disease c. Living in a rural area d. Being part of a busy family
ANS: B Older adults are at high risk for violence, particularly those with cognitive impairments. The other characteristics are not identified as placing an individual at high risk.
7. A hospitalized patient diagnosed with an alcohol abuse 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
ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the patients feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.
3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic
ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority.
3. 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
ANS: B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.
6. A nurse in the emergency department assesses an unresponsive victim of rape. The victims friend reports, That guy gave her salty water before he raped her. Which question is most important for the nurse to ask of the victims 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?
ANS: B Salty water is a slang/street name for GHB (g-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victims physiologic stability.
6. A hospitalized patient diagnosed with an alcohol abuse 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 (Dilaudid). b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium). c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).
ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.
24. 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. Youre evil. This outburst can be assessed as: a. denial. b. splitting. c. defensive. d. reaction formation.
ANS: B Splitting involves loving a person, then hating the person because the patient is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness.
4. 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 nurses 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.
ANS: B Strong negative feelings cloud the nurses judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to over-involvement with victims rather than healthy transference.
19. In the emergency department, a patients vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic 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/min, and respirations at or above 12 breaths/min. 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 patients breath sounds will be clear bilaterally and throughout lung fields.
ANS: B The correct short-term outcome is the only one that relates to the patients physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patients respirations are slow and shallow, but there is no evidence of congestion.
28. 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.
ANS: B The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD.
30. A patient says, The other nurses wont give me my medication early, but you know what its like to be in pain and dont let your patients suffer. Could you get me my pill now? I wont tell anyone. Which response by the nurse would be most therapeutic? a. Im 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. Ill 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.
ANS: B The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the patient the nurses understanding of the patients distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the patient.
18. An older woman diagnosed with Alzheimers 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. Shes awake all night. I never get any sleep. Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowners syndrome. b. Secure additional resources for the mothers evening and night care. c. Support the caregiver to grieve the loss of the mothers cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.
ANS: B The patients caregivers were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.
26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality disorders is: a. noncompliance. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.
ANS: B Without exception, individuals with personality disorders have problems with social interaction with others, hence, the diagnosis of impaired social interaction. For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to patients with personality disorders; each might apply to selected clinical diagnoses, but not to others.
14. 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.
ANS: C Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.
5. 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.
ANS: B, D As uncomfortable as the victim may be, she should not bathe until the examination is completed. Collection of evidence is critical for prosecution of the attacker. Showering after the examination will provide comfort to the victim. The distracters will result in destruction of evidence or are untrue.
1. 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
ANS: B, D Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.
10. 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 patients 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 patients behavior.
ANS: C A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the patient is able to behave appropriately.
6. What is a nurses legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the childs 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.
ANS: C Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.
2. An 11-year-old reluctantly tells the nurse, My parents dont like me. They said they wish I was never born. Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic
ANS: C Examples of emotional abuse include having an adult demean a childs worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.
25. Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the patients 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
ANS: C Frequent team meetings are held to counteract the effects of the patients attempts to split staff and set them against one another, causing interpersonal conflict. Patients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.
7. 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.
ANS: C Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.
15. 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
ANS: C Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurses observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.
6. 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
ANS: C Limits must be set in areas in which the patients behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.
5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, Another nurse said you dont do your job right. Collectively, these interactions can be assessed as: a. seductive. c. manipulative. b. detached. d. guilt-producing.
ANS: C Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evident in the comments.
20. 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
ANS: C Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident.
10. 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? 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. Im 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.
ANS: C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victims sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.
4. 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/min. The patient shouts, Bugs are crawling on my bed. Ive 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.
ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.
12. An adult tells the nurse, My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. Ive considered leaving but havent 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
ANS: C The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.
13. 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.
ANS: C The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity.
3. 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. Ill take it when I finish combing my hair. What is the nurses best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, Im worried that you might not take it. Ill come back later. c. Say to the patient, I must watch you take the medication. Please take it now. d. Ask the patient, Why dont you want to take your medication now?
ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patients safety, but also to prevent splitting other staff. Why questions are not therapeutic.
11. 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 anti-anxiety medication to decrease the anxiety level.
ANS: C The patient has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for coaching during crises. The nurse can assist the patient to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the patient is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the patients ability to weigh alternatives to mutilating behavior.
27. A new psychiatric technician says, Schizophrenia...schizotypal! Whats the difference? The nurses 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.
ANS: C The patient with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.
4. 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.
ANS: C This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.
8. A rape victim tells the nurse, I should not have been out on the street alone. Select the nurses 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.
ANS: D A reflective communication technique is most helpful. Looking at ones role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victims perceived role and interfere with further discussion.
2. 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 womans level of anxiety? a. Weak b. Mild c. Moderate d. Severe
ANS: D Acute anxiety results from the personal threat to the victims safety and security. In this case, the patients symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.
10. 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 nurses next action? a. Call the police. c. Call the adult protective agency. b. Arrange for hospitalization. d. Document injuries with a body map.
ANS: D Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.
1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, If I avoid strangers or situations where I am alone outside at night, Ill be safe from sexual attacks. Choose the nurses 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. Its better to walk with someone or call security when you enter or leave a building. d. Sexual assaults are more often perpetrated by acquaintances. Lets discuss ways to prevent that.
ANS: D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.
15. Before a victim of sexual assault is discharged from the emergency department, the nurse should: a. notify the victims 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.
ANS: D Immediately after the assault, rape victims are often disorganized and unable to think well or remember instructions. Written information acknowledges this fact and provides a solution. The distracters violate the patients right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.
19. 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.
ANS: D Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder.
12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)
ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.
20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, How can we help? Select the nurses best response. a. Alcoholism is a lifelong disease. Relapses are expected. b. Use search and destroy tactics to keep the home alcohol free. c. Its important that you visit your family member on a regular basis. d. Make your loved one responsible for the consequences of behavior.
ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.
17. 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.
ANS: D The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in patients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.
8. A patient diagnosed with an alcohol abuse 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.
ANS: D The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurses frustration with the patient.
21. Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system d. Achieve physiologic stability.
ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.
9. 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 nurses priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries
ANS: D The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options.
8. A patients spouse filed charges after repeatedly being battered. The patient sarcastically says, Im sorry for what I did. I need psychiatric help. Which statement by the patient supports an antisocial personality disorder? a. I have a quick temper, but I can usually keep it under control. b. Ive done some stupid things in my life, but Ive learned a lesson. c. Im 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.
ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.
5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs 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
ANS: D The patients clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurses priority. The other diagnoses may apply but are not the priorities of care.
4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, I cant talk about it. Nothing happened. I have to forget. What is the patients present coping strategy? a. Compensation b. Somatization c. Projection d. Denial
ANS: D The patients statements reflect use of denial, an ego defense mechanism. This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape. The patients statements do not reflect somatization, compensation, or projection.
18. 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.
ANS: D This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other patients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to patient compliance.