notes 4

13. The nurse is educating a client diagnosed with Munchausen syndrome. Which statement made by the nurse is correct? 1. "A characteristic of your disorder is that you fabricate signs and symptoms of illness." 2. "Having your condition means that you hear voices that guide your actions." 3. "Your condition causes you to experience a change in body function that cannot be explained." 4. "Your symptom of memory loss is very common in your condition."

1. "A characteristic of your disorder is that you fabricate signs and symptoms of illness."

10. Chinese physicians prescribed several complementary therapies more than 5000 years ago. Which therapy is based on the theory that health energy flows along meridians in the body? 1. Acupuncture treatments 2. Massage movements 3. Herbal remedies 4. Chiropractic manipulations

1. Acupuncture treatments

15. Which concepts are considered part of the grief response? Select all that apply. 1. Bereavement 2. Mourning 3. Denial 4. Loss

1. Bereavement 2. Mourning

10. A client reports during his visit to the mental health clinic that he is distressed by repetitive sexual fantasies that involve humiliating his sexual partner. This would most appropriately be assessed by the nurse as which type of disorder? 1. Paraphilic disorder 2. Obsessive-compulsive disorder 3. Erectile disorder 4. Hypoactive sexual desire disorder

1. Paraphilic disorder

18. The nurse is administering clozapine to a client diagnosed with schizophrenia. Which symptoms require the nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

1. Sore throat, fever, and malaise

20. A healthy 54-year-old client is the president of a hedge fund. The client works long hours and travels extensively for work. Her spouse of 30 years notices that she has been distracted lately and is not as interested in sex as she used to be. The couple has not had intercourse in over6 months, which is unusual for them. When asked about her mood, the client states, "I have to lay off 50 employees at work, and it is just killing me. I feel so hopeless and overwhelmed. I know I'm not being a good partner to you, and this really worries me." Which short-term nursing goal is most appropriate for the client? Select all that apply. 1. The client will identify stressors that may contribute to loss of sexual desire within 1 week. 2. The client will resume sexual activity at a level satisfactory to self and partner within 6 months. 3. The client will identify three symptoms of depression that may contribute to loss of sexual desire within 2 weeks. 4. The client will verbalize willingness to seek professional assistance from a sex therapist to learn alternate ways of achieving sexual satisfaction within 2 months.

1. The client will identify stressors that may contribute to loss of sexual desire within 1 week. 3. The client will identify three symptoms of depression that may contribute to loss of sexual desire within 2 weeks.

4. The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse's best reply? 1. "Tell him to stop talking about the voices." 2. "Ask him what the voices are saying to him." 3. "Tell him you know the voices are real to him." 4. "Encourage him not to worry about the voices."

2. "Ask him what the voices are saying to him."

Chapter 40 1. A nursing instructor is teaching about complementary therapies. Which student statement indicates that learning has occurred? 1. "Complementary therapies view all humans as being biologically similar." 2. "Complementary therapies view a person as a combination of multiple integrated elements." 3. "Complementary therapies focus primarily on the structure and functions of the body." 4. "Complementary therapies view disease as a deviation from a normal biological state."

2. "Complementary therapies view a person as a combination of multiple integrated elements."

7. The nurse tells the parents of an adolescent diagnosed with anorexia nervosa, "The social worker will be contacting you to schedule a family meeting." One of the client's parents states, "Why is that necessary? Our child is the one who needs treatment." Which response by the nurse is best? 1. "We expect every client and their family to attend two family sessions." 2. "Family intervention and support are important in managing eating disorders." 3. "The sessions are used to educate all family members about eating disorders. 4. "During the meeting you will be able to resolve conflicts with your child."

2. "Family intervention and support are important in managing eating disorders."

22. A 6-year-old client is prescribed methylphenidate for a diagnosis of ADHD. When teaching the parents about this medication, which nursing statement explains how methylphenidate works? 1. "Methylphenidate's sedation side effect assists children by decreasing their energy level." 2. "How methylphenidate works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD." 3. "Methylphenidate helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapses." 4. "Methylphenidate decreases hyperactivity by increasing serotonin levels."

2. "How methylphenidate works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD."

Chapter 42 1. A 52-year-old client states, "My spouse is upset because I don't enjoy sex as much as I used to." Which priority client data would the nurse initially collect? 1. History of hysterectomy 2. Date of last menstrual cycle 3. Use of birth control methods 4. History of thought disorder

2. Date of last menstrual cycle

12. According to the U.S. Census Bureau criterion, how would a nurse classify a 70-year-old man? 1. This man would be classified as "older." 2. This man would be classified as "elderly." 3. This man would be classified as "aged." 4. This man would be classified as "very old."

2. This man would be classified as "elderly."

2. The nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, "I'm planning an elaborate wake and funeral." According to George Engel, which purpose do these rituals serve? 1. To delay the recovery process initiated by the loss of the client's spouse 2. To facilitate the acceptance of the loss of the client's spouse 3. To avoid dealing with grief associated with the loss of the client's spouse 4. To eliminate emotional pain related to the loss of the client's spouse

2. To facilitate the acceptance of the loss of the client's spouse

30. The nursing instructor asks a nursing student to describe concepts of the Recovery Model. Which concepts should the nursing student include? Select all that apply. 1. Employs positive and negative reinforcement 2. Uses personal values to determine meaning in life 3. Focuses on interactions within a social environment 4. Centers on improving adherence to prescribed medications 5. Allows client primary control over care decisions

2. Uses personal values to determine meaning in life 5. Allows client primary control over care decisions

14. A nursing instructor is teaching about the various categories of paraphilic disorders. Which categories are correctly matched with expected behaviors? Select all that apply. 1. Exhibitionistic disorder: A client models lingerie for a company that specializes in home parties. 2. Voyeuristic disorder: A client is arrested for peering in a neighbor's bathroom window. 3. Frotteuristic disorder: A client enjoys subway rush-hour contact with others that results in arousal. 4. Pedophilic disorder: A client can experience an orgasm by holding and feeling shoes. 5. Fetishistic disorder: A client masturbates into his wife's silk panties.

2. Voyeuristic disorder: A client is arrested for peering in a neighbor's bathroom window. 3. Frotteuristic disorder: A client enjoys subway rush-hour contact with others that results in arousal. 5. Fetishistic disorder: A client masturbates into his wife's silk panties.

9. A client diagnosed with brief psychotic disorder states, "The voices keep telling me I must kill the president." Which is the priority nursing diagnosis? 1. Disturbed sensory perception 2. Disturbed thought processes 3. Risk for violence: other directed 4. Impaired verbal communication

3. Risk for violence: other directed

8. The nurse assesses a woman whose spouse died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process? 1. Stage I: numbness or protest 2. Stage II: disequilibrium 3. Stage III: disorganization and despair 4. Stage IV: reorganization

3. Stage III: disorganization and despair

17. The nurse is reviewing assessment data of a client diagnosed with anorexia nervosa. The client's BMI dropped from 17 to 15.5 kg/m2 over the past 3 months. Which client statement best supports the assessment data? 1. "I'm glad I don't make myself throw up." 2. "My hair started falling out last week." 3. "You don't know what it's like to be fat." 4. "At least I am not gaining any weight."

4. "At least I am not gaining any weight."

5. A client asks the nurse to explain the difference between complementary and alternative medicine. Which is an appropriate nursing reply? 1. "Alternative medicine is a more acceptable practice than is complementary medicine." 2. "Alternative medicine and complementary medicine are terms that essentially mean the same thing." 3. "Complementary medicine disregards traditional medical approaches." 4. "Complementary therapies partner alternative medicine with traditional medical practice."

4. "Complementary therapies partner alternative medicine with traditional medical practice."

15. The nurse is caring for a client diagnosed with conversion disorder. Which statement made by the nurse is most therapeutic for this client? 1. "I think you could get over this condition if you tried hard enough. A positive outlook can change everything." 2. "I'm so sorry that your back hurts so much. Yes, I'm happy to get you a wheelchair so you don't have to walk to meals." 3. "I think that your symptoms are just in your head. Therapy can help you get rid of them." 4. "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties.'

4. "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties.'

5. A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, "My wife is having an affair with a young man, and I want it investigated." Which is the appropriate nursing reply? 1. "Your wife loves you too much to have an affair." 2. "Why do you think that your wife is having an affair?" 3. "Your wife has told us that these thoughts have no basis in fact." 4. "I understand that you are upset. Let's talk about it."

4. "I understand that you are upset. Let's talk about it."

6. The nurse is assessing an adolescent who was brought to the emergency department after collapsing during Olympic figure skating training. The adolescent is diagnosed with severe malnutrition due to anorexia nervosa. Which client statement supports the use of a family-based approach? 1. "I just didn't drink enough water during practice." 2. "I eat just as much as everyone else on the team." 3. "I have to practice until my skating routine is perfect." 4. "I'm tired of fighting with my parents about eating."

4. "I'm tired of fighting with my parents about eating."

20. The client is an older adult widower who lives in a long-term care facility. Recently, he has been complaining of fatigue, sleeping excessively, and refusing to engage in unit activities, including meals. When the nurse asks him about these symptoms he sighs, "Don't worry about me. I'm just a tired old man who is waiting to die." Which questions are most important for the nurse to ask him? Select all that apply. 1. "Are you thinking of hurting yourself?" 2. "Should I call your family to cheer you up?" 3. "How long have you been feeling this way?" 4. "Would you feel better if you came to dinner?" 5. "Would it be better if I left you alone for a bit?"

1. "Are you thinking of hurting yourself?" 3. "How long have you been feeling this way?"

3. A 16-year-old client diagnosed with schizophrenia is experiencing auditory command hallucinations. The client reports the voices are telling him to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the nurse's most appropriate reply? 1. "Auditory hallucinations are caused by increased dopamine levels in the brain." 2. "Hallucinations can be caused by medication interactions." 3. "Hallucinations occur when there is not enough serotonin in the brain." 4. "Auditory hallucinations are mainly due to abnormal hormonal changes."

1. "Auditory hallucinations are caused by increased dopamine levels in the brain."

19. A client is exhibiting symptoms of generalized amnesia. Which questions would the nurse ask to confirm this diagnosis? Select all that apply. 1. "Can you tell me your name and where you live?" 2. "Have you ever traveled suddenly or unexpectedly away from home?" 3. "Have you recently experienced any traumatic event?" 4. "Have you ever felt detached from your environment?" 5. "Have you had any history of memory problems?"

1. "Can you tell me your name and where you live?" 5. "Have you had any history of memory problems?"

10. A nursing instructor is teaching students about eating disorders. Which statement indicates that a student understands the differences between anorexia nervosa and bulimia nervosa? 1. "Clients diagnosed with anorexia nervosa exhibit malnutrition and dehydration." 2. "Hyperkalemia and hyponatremia are associated with anorexia nervosa." 3. "Signs of bulimia nervosa include hypotension, edema, and erosion of tooth enamel." 4. "Amenorrhea and parotid gland enlargement are symptoms of bulimia nervosa."

1. "Clients diagnosed with anorexia nervosa exhibit malnutrition and dehydration."

5. Which student statement about clients diagnosed with this disorder indicates that learning has occurred regarding the etiology of dissociative disorders from a psychoanalytical perspective? 1. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." 2. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. 3. "People with dissociative disorders typically have strong egos." 4. "There is clear and convincing evidence of a familial predisposition to this disorder."

1. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness."

18. Which statement made by a student indicates an understanding of the teaching regarding gender dysphoria? Select all that apply. 1. "Gender identity does not dictate to whom one is attracted." 2. "Gender dysphoria is caused by an increase in female hormones." 3. "The majority of transgender individuals are men who wish to reassign to female gender." 4. "Impaired family dynamics lead to gender dysphoria."

1. "Gender identity does not dictate to whom one is attracted." 3. "The majority of transgender individuals are men who wish to reassign to female gender."

21. A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care? Select all that apply. 1. "Have you had thoughts of self-harm?" 2. "How many physicians have you seen in the past 6 months?" 3. "Do you take medication for anxiety as prescribed?" 4. "When did you last feel detached from your environment?" 5. "How long have you had these memory problems?"

1. "Have you had thoughts of self-harm?" 2. "How many physicians have you seen in the past 6 months?" 3. "Do you take medication for anxiety as prescribed?"

17. The client is an older adult who has bilateral cataracts. Which statement made by the nurse indicates implementation of appropriate nursing interventions for this client? Select all that apply. 1. "I've arranged your plate so your meat is at one o'clock, veggies are at six o'clock, and potatoes are at nine o'clock." 2. "I need to ask you a question. Please look at my face while I'm speaking to you." 3. "I'm going to turn your television down so you can hear what your guests are saying to you." 4. "I know you have felt isolated, so I signed you up for the crafts activity this afternoon." 5. "I've placed the television remote, your book, and a box of tissues on your tray table."

1. "I've arranged your plate so your meat is at one o'clock, veggies are at six o'clock, and potatoes are at nine o'clock." 2. "I need to ask you a question. Please look at my face while I'm speaking to you." 5. "I've placed the television remote, your book, and a box of tissues on your tray table."

12. The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which response by the nurse is evidence based? 1. "Most symptoms of conversion disorder resolve within a few weeks." 2. "Typically, people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." 3. "The only people who recover are those who develop conversion disorder symptoms without a precipitating stressful event." 4. "Technically, he could walk now since he is intentionally feigning paralysis."

1. "Most symptoms of conversion disorder resolve within a few weeks."

23. The nurse is visiting with a child with suspected ADHD. Which statement by the parent supports the nurse's suspicion? 1. "My child has been doing poorly in his schoolwork because he can't stay in his seat." 2. "My son never takes responsibility for his actions. It is always someone else's fault." 3. "My daughter told me she saw my son kick our neighbor's dog." 4. "I wish I could get my son to eat other foods. All he will eat are chips because they are crunchy."

1. "My child has been doing poorly in his schoolwork because he can't stay in his seat."

13. Which statement indicates to the nurse that a client is experiencing a delusion? 1. "Spies are watching everything I do." 2. "There is a worm on the back of the television." 3. "Bugs are crawling all over me." 4. "I really don't feel like going to group today."

1. "Spies are watching everything I do."

2. A child who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply? 1. "Support groups are held here on Mondays for children of residents." 2. "You did what you had to do. I wouldn't feel guilty if I were you." 3. "Support groups are available to low-income families." 4. "Your parent is doing just fine. We'll take very good care of him."

1. "Support groups are held here on Mondays for children of residents."

16. A nursing instructor presents a case study in which a 3-year-old is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which response indicates that the student has evaluated the situation appropriately? 1. "This child's behavior must be evaluated according to developmental norms." 2. "This child has symptoms of attention deficit-hyperactivity disorder (ADHD)." 3. "This child has symptoms of the early stages of ASD." 4. "This child's behavior indicates possible symptoms of ODD."

1. "This child's behavior must be evaluated according to developmental norms."

4. A client diagnosed with chronic migraine headaches is considering acupuncture. The client asks a clinic nurse, "How does this treatment work?" Which is the best response by the nurse? 1. "Western medicine believes that acupuncture stimulates the body's release of pain fighting chemicals called endorphins." 2. "I'm not sure why he suggested acupuncture. There are a lot of risks, including HIV." 3. "Acupuncture works by encouraging the body to increase its development of serotonin and norepinephrine." 4. "Your acupuncturist is your best resource for answering your specific questions."

1. "Western medicine believes that acupuncture stimulates the body's release of pain fighting chemicals called endorphins."

19. A 32-year-old heterosexual client is arrested for masturbating while hiding in his neighbors' shrubs and watching them engage in sexual activity in their outdoor hot tub. The nurse is conducting a sexual history to gain data to create the client's plan of care. Which questions asked by the nurse will elicit the most important client data? Select all that apply. 1. "Who are your closest friends, and how much time do you spend with them?" 2. "Are you able to become sexually aroused when interacting with an attractive woman?" 3. "What is your gender, and how would you describe your feelings about your gender?" 4. "How much time do you spend on the Internet looking at child pornography?"

1. "Who are your closest friends, and how much time do you spend with them?" 2. "Are you able to become sexually aroused when interacting with an attractive woman?" 3. "What is your gender, and how would you describe your feelings about your gender?"

30. Which risk factors noted during a family history assessment would the nurse associate with the potential development of ID? Select all that apply. 1. A family history of Tay-Sachs disease 2. Childhood meningococcal infection 3. Deprivation of nurturance and social contact 4. History of maternal multiple motor and verbal tics 5. A diagnosis of maternal major depressive disorder

1. A family history of Tay-Sachs disease 2. Childhood meningococcal infection 3. Deprivation of nurturance and social contact

8. A newly married individual comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. Which initial intervention would the nurse expect a physician to implement? 1. A thorough physical to include gynecological examination 2. Referral to a sex therapist 3. Assessment of sexual history and previous satisfaction with sexual relationships 4. Referral to the recreational therapist for relaxation therapy

1. A thorough physical to include gynecological examination

12. The nurse is leading a bereavement group. Which group members would the nurse identify as being at high risk for having difficulty grieving? Select all that apply. 1. A widower who has recently experienced the death of two good friends 2. A man whose spouse died suddenly after a cerebrovascular accident 3. A woman who, after a year, allowed removal of life support from her terminally ill spouse 4. A woman who had a competitive relationship with her recently deceased sibling 5. A young couple whose child recently died of a genetic disorder

1. A widower who has recently experienced the death of two good friends 2. A man whose spouse died suddenly after a cerebrovascular accident 4. A woman who had a competitive relationship with her recently deceased sibling 5. A young couple whose child recently died of a genetic disorder

17. Which scenario best describes Munchausen by proxy? 1. A wife makes her husband ill so she can be seen as the hero when bringing him to the emergency department. 2. A client uses three personalities to block out the trauma of sexual abuse experienced as a child. 3. A former soldier thinks back to an experience and sees himself observing from a distance and wonders what he would do in that situation. 4. A client has a strong desire to be pregnant and has morning sickness and symptoms associated with pregnancy but has a negative pregnancy test.

1. A wife makes her husband ill so she can be seen as the hero when bringing him to the emergency department.

6. Which situation will most likely lead to maladaptive grief in the survivor? 1. A woman loses her spouse, who was the primary breadwinner of the family. 2. A man loses a sibling 15 years after losing his other sibling. 3. A man loses his spouse and has been attending a support group for 3 months. 4. A woman loses her colleague to a heroin overdose.

1. A woman loses her spouse, who was the primary breadwinner of the family.

16. Aisha has just experienced the unexpected death of a parent. Which criteria may the nurse use for measurement of outcomes in Aisha's grief care? Select all that apply. 1. Acknowledges awareness of the loss 2. Expresses feelings about the loss 3. Verbalizes positive aspects about her life at present and in the future 4. Expresses anger toward the loss appropriately 5. Expresses personal satisfaction and support from spiritual practices

1. Acknowledges awareness of the loss 2. Expresses feelings about the loss 5. Expresses personal satisfaction and support from spiritual practices

13. When planning care for a client, which medication classification would the nurse recognize as effective in the treatment of Tourette's disorder? 1. Antipsychotic medications 2. Antimanic medications 3. Tricyclic antidepressant medications 4. Monoamine oxidase inhibitor (MAOI) medications

1. Antipsychotic medications

9. A nursing student read a textbook chapter about the therapeutic strategy of a psychosocial therapy. The author suggested a spoken script, responding as a "broken record," repeating a statement again and again as needed. Which psychosocial therapy is being described? 1. Assertiveness training 2. Relaxation therapy 3. Cognitive behavior therapy 4. Chiropractic exercises

1. Assertiveness training

21. The nurse is assessing a client newly admitted to the eating disorders unit. Which findings indicate the client may have a diagnosis of bulimia nervosa? Select all that apply. 1. BMI of 24 kg/m2 2. Amenorrhea 3. Erosion of tooth enamel 4. Lanugo 5. Russell's sign

1. BMI of 24 kg/m2 3. Erosion of tooth enamel 5. Russell's sign

31. Which interventions would the nurse anticipate implementing when planning care for children diagnosed with ADHD? Select all that apply. 1. Behavior modification 2. Antianxiety medications 3. Competitive group sports 4. Group therapy 5. Family therapy

1. Behavior modification 4. Group therapy 5. Family therapy

6. An adolescent client who was diagnosed with conduct disorder at the age of 8 years is sentenced to juvenile detention after bringing a gun to school. Which statement indicates the nurse's understanding of conduct disorder related to this client's situation? 1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. 2. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. 3. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5 years; therefore, improvement is likely. 4. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive ODD.

1. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood.

15. Which statement regarding sexual development in late childhood is true? Select all that apply. 1. Children this age engage in both heterosexual and homosexual play. 2. Children this age become interested in menstruation, pregnancy, and birth. 3. Children this age become self-conscious about their bodies. 4. Children this age engage in touching and kissing that mirrors behavior of their parents. 5. Children this age become aware of anatomical sex differences.

1. Children this age engage in both heterosexual and homosexual play. 2. Children this age become interested in menstruation, pregnancy, and birth. 3. Children this age become self-conscious about their bodies.

11. Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care would be included for this client? 1. Deal with physical symptoms in a detached manner. 2. Challenge the validity of physical symptoms. 3. Meet dependency needs until the physical limitations subside. 4. Encourage a discussion of feelings about the lower-extremity problem

1. Deal with physical symptoms in a detached manner.

13. Which of the following practices should the nurse describe to a client as being incorporated during yoga therapy? Select all that apply. 1. Deep breathing 2. Meridian therapy 3. Balanced body postures 4. Massage therapy 5. Meditation

1. Deep breathing 3. Balanced body postures 5. Meditation

26. The psychiatric-mental health nurse is evaluating the care of a client recovering from an episode of psychosis. Which is the most appropriate long-term goal for the client? 1. Define and test reality. 2. Participate in social activities. 3. Maintain appropriate eye contact. 4. Verbalize feelings of anxiety.

1. Define and test reality.

2. The nurse is working with a client diagnosed with somatic symptom disorder. Which predominant symptoms would the nurse expect to assess? 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms 2. Amnestic episodes in which the client is pain free 3. Excessive time spent discussing psychosocial stressors 4. Lack of physical symptoms

1. Disproportionate and persistent thoughts about the seriousness of one's symptoms

11. An elderly client has met the criteria for a diagnosis of major depressive disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client? 1. Electroconvulsive therapy (ECT) 2. Neuroleptic therapy 3. An antiparkinsonian agent 4. An anxiolytic agent

1. Electroconvulsive therapy (ECT)

18. The nurse assigns the nursing diagnosis "ineffective coping related to feelings of helplessness" to a client diagnosed with bulimia nervosa. Which is the most appropriate outcome related to this nursing diagnosis? 1. Exhibits ability to use adaptive strategies to cope with emotional issues 2. Achieves and maintains an expected BMI for weight and age 3. Demonstrates positive self-esteem by verbalizing positive aspects of self 4. Identifies consequences of fluid loss caused by self-induced vomiting

1. Exhibits ability to use adaptive strategies to cope with emotional issues

15. The nursing instructor is teaching a course on human growth and development to a class of nursing students. The teaching is successful when the students identify which factors as biological aspects of aging? Select all that apply. 1. Fat redistribution 2. Heart hypertrophy 3. Increased fibrous lung tissue 4. Thickening of muscle fibers 5. Enlargement of the liver

1. Fat redistribution 2. Heart hypertrophy 3. Increased fibrous lung tissue

2. The nurse is preparing an education program regarding early identification of students at risk for developing anorexia nervosa. Which client does the nurse recognize as having the highest risk of developing an eating disorder? 1. Female ballet dancer 2. Female cheerleader 3. Male wrestler 4. Male swimmer

1. Female ballet dancer

9. The nurse is teaching parents of a 14-year-old client diagnosed with anorexia nervosa about prescribed medications. Which carries a black-box warning? 1. Fluoxetine 2. Phenelzine 3. Topiramate 4. Amitriptyline

1. Fluoxetine

27. When planning care for clients diagnosed with schizophrenia, which of the following should the nurse recognize as an integral part of a rehabilitative program? Select all that apply. 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

1. Group therapy 2. Medication management 4. Supportive family therapy 5. Social skills training

22. A 56-year-old is brought to the emergency department by the police because she was found wandering confusedly in a busy shopping center several miles from her home. The nurse assesses the client and finds that she has been the victim of domestic violence for 32 years and has recently been beaten by her spouse. Her recollection of current events is hazy and she is not able to give the nurse a detailed account of the abuse. Which of the client's symptoms cause the nurse to suspect that she is suffering from dissociative fugue? Select all that apply. 1. Her trip to a shopping center several miles from her home 2. The client's confused wandering 3. Her ability to stay with an abuser all these years 4. The client's inability to offer details about the domestic abuse 5. Her inability to focus on the questioning

1. Her trip to a shopping center several miles from her home 2. The client's confused wandering 4. The client's inability to offer details about the domestic abuse

21. The nurse is assessing a client for potential sexually transmitted infections (STIs). Which questions are appropriate for the nurse to include in the assessment? Select all that apply. 1. How many sexual partners have you had within the past year? 2. What religion do you practice? 3. Have you ever been diagnosed with an STI? 4. Do you use any form of protection against STIs and, if so, what kind? 5. Are you able to easily achieve orgasm? 6. In what kind of sexual activities do you participate?

1. How many sexual partners have you had within the past year? 3. Have you ever been diagnosed with an STI? 4. Do you use any form of protection against STIs and, if so, what kind? 6. In what kind of sexual activities do you participate?

7. The nurse is assessing a new client diagnosed with schizophrenia. The client states "Those people behind the desk won't stop laughing at me." The nurse determines the client is experiencing which symptom? 1. Ideas of reference 2. Loose associations 3. Delusion of influence 4. Tangentiality

1. Ideas of reference

17. A 42-year-old, lesbian, premenopausal client visits her gynecologist for an annual examination. The nurse visits with the client before the examination and informs her of the symptoms of menopause that she may begin to experience. Which symptoms would the nurse teach the client? Select all that apply. 1. Insomnia 2. Heart palpitations 3. Depression 4. Vaginal discharge

1. Insomnia 2. Heart palpitations 3. Depression

19. When a person is at risk for spiritual distress, for which reasons is it an appropriate nursing intervention to stay with the client and accepting and nonjudgmental when the client expresses anger and bitterness (e.g., toward God, the universe)? Select all that apply. 1. It increases the client's feelings of self-worth. 2. It promotes trust in the nurse-client relationship. 3. It validates the client's feelings. 4. It serves to provide relief from spiritual distress.

1. It increases the client's feelings of self-worth. 2. It promotes trust in the nurse-client relationship.

3. A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her spouse planned. According to Worden, which indicates the effect the neighbors' action may have on the woman's grieving task completion? 1. It may hamper the woman from accepting the reality of the loss. 2. It would help the woman forget the sorrow and move on with life. 3. It communicates full support from her neighbors. 4. It would motivate the woman to look to the future and not the past.

1. It may hamper the woman from accepting the reality of the loss.

14. The nurse documents assessment findings of a client who is unable to recall all specifics related to compound childhood traumas. Which disorder is the client experiencing? 1. Localized amnesia 2. Selective amnesia 3. Generalized amnesia 4. Retrograde amnesia

1. Localized amnesia

16. Which evidence-based statement regarding adolescent coitus is accurate? Select all that apply. 1. More adolescents are engaging in premarital intercourse. 2. The incidence of premarital intercourse for girls has increased. 3. The average age of first intercourse has decreased. 4. The majority of adolescent boys do not use condoms during intercourse

1. More adolescents are engaging in premarital intercourse. 2. The incidence of premarital intercourse for girls has increased. 3. The average age of first intercourse has decreased.

18. A client is diagnosed with illness anxiety disorder. Which symptoms is the client most likely to exhibit? Select all that apply. 1. Obsessive-compulsive traits 2. Pseudocyesis 3. Disabling fear of having a serious illness 4. Multiple pronounced physical symptoms 5. Depression

1. Obsessive-compulsive traits 3. Disabling fear of having a serious illness 5. Depression

6. A client has been taking 1200 mg/day of St. John's wort during the past year for symptoms of depression. Recently, the client complained of side effects from this herbal remedy. Which symptom should the nurse expect the client to report? 1. Photosensitivity 2. Insomnia 3. Hirsutism 4. Restlessness

1. Photosensitivity

14. Which types of care would the interdisciplinary team of hospice provide? Select all that apply. 1. Physical care available on a 24-7 basis 2. Counseling on the addictive properties of pain management medications 3. Discussions related to death and dying 4. Explorations of new, aggressive treatments 5. Assistance with obtaining spiritual support and guidance

1. Physical care available on a 24-7 basis 3. Discussions related to death and dying 5. Assistance with obtaining spiritual support and guidance

31. The parent of a 20-year-old client recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia? Select all that apply. 1. Prostaglandins 2. Glutamate 3. Thyroxine 4. Dopamine 5. Erythropoietin

1. Prostaglandins 2. Glutamate 4. Dopamine

13. An instructor is teaching nursing students about Worden's grief process. Which client behaviors serve to delay or prolong the grieving process? Select all that apply. 1. Refusing to allow self to think painful thoughts 2. Indulging in the pain of loss 3. Using alcohol and drugs 4. Idealizing the object of loss 5. Recognizing that time will heal the grief

1. Refusing to allow self to think painful thoughts 3. Using alcohol and drugs 4. Idealizing the object of loss

15. A client who prefers to use St. John's wort and psychotherapy in lieu of antidepressant therapy asks for tips on using herbal remedies. Which teaching points should the nurse provide? Select all that apply. 1. Select a reputable brand. 2. Increasing dosage does not lead to improved effectiveness. 3. Monitor for adverse reactions. 4. Gradually increase dosage to gain maximum effect. 5. Most herbal remedies are best absorbed on an empty stomach.

1. Select a reputable brand. 2. Increasing dosage does not lead to improved effectiveness. 3. Monitor for adverse reactions.

2. In the course of an assessment interview, a client reveals a history of bisexual orientation. Which action would the nurse initially implement when working with this client? 1. Self-assess personal attitudes toward bisexuality. 2. Review client's possible childhood sexual abuse history. 3. Encourage discussion of aversion to heterosexual relationships. 4. Explore client's family history of homosexuality and bisexuality

1. Self-assess personal attitudes toward bisexuality.

29. Why would a nurse establish goals for a client diagnosed with ADHD presenting with low frustration tolerance and short attention span that allow the client to complete part of the task, rewarding each step completion with a break for physical activity? 1. Short-term goals are not so overwhelming for clients with a short attention span. 2. Repetition of instructions helps to determine the client's level of comprehension. 3. This encourages the client to perform independently while providing a feeling of security. 4. The client lacks the ability to assimilate information that is complicated or has abstract meaning.

1. Short-term goals are not so overwhelming for clients with a short attention span.

12. The nurse expects a client experiencing prodromal symptoms of schizophrenia to demonstrate which of the following? 1. Significant deterioration in functioning 2. Poor relationships with peers 3. Disturbances in thought processing 4. Disorganized motor behavior

1. Significant deterioration in functioning

28. The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the mediation to have a therapeutic effect on which symptoms? Select all that apply. 1. Somatic delusions 2. Social isolation 3. Gustatory hallucinations 4. Flat affect 5. Clang associations

1. Somatic delusions 3. Gustatory hallucinations 5. Clang associations

13. Which characteristics would the nurse identify as normal in the development of human sexuality for an 11-year-old child? Select all that apply. 1. The child experiments with masturbation. 2. The child may experience homosexual play. 3. The child shows little interest in the opposite sex. 4. The child shows little concern about physical attractiveness. 5. The child is unlikely to want to undress in front of others.

1. The child experiments with masturbation. 2. The child may experience homosexual play. 5. The child is unlikely to want to undress in front of others

12. The nurse suspects a client in the support group has frotteuristic disorder. Which statement supports the nurse's suspicion? 1. The client purposely brushes up against unsuspecting women on the bus, feeling their breasts. 2. The client observes his unsuspecting neighbor dressing for work in the morning. 3. The client dresses in women's clothing and goes to the local bar. 4. The client uses his wife's stockings to achieve an orgasm.

1. The client purposely brushes up against unsuspecting women on the bus, feeling their breasts.

15. A child diagnosed with ASD has the nursing diagnosis of disturbed personal identity. Which outcome best addresses this client's diagnosis? 1. The client will name own body parts as separate from others by day 5. 2. The client will establish a means of communicating personal needs by discharge. 3. The client will initiate social interactions with caregivers by day 4. 4. The client will not harm self or others by discharge.

1. The client will name own body parts as separate from others by day 5.

23. A client is diagnosed with a dissociative disorder. Which actions would the nurse take when teaching the client about her disorder? Select all that apply. 1. The nurse should determine if the client is anxious. 2. The nurse should explore the client's fears. 3. The nurse should ask the physician to explain test results to the client. 4. The nurse should ask the family to engage in role-play.

1. The nurse should determine if the client is anxious. 2. The nurse should explore the client's fears.

17. The mother of a 6-month-old child was diagnosed with a terminal illness and died just 4 days after her child's first birthday. At the 1-year well-child visit, the spouse shares some concerns with the pediatrician regarding changes in the child's normal behavior. Which are common changes in children from birth to age 2 years when they are separated from their mothers? Select all that apply. 1. Weight loss 2. Increased bowel movements 3. Sleeplessness 4. Reduced eye contact

1. Weight loss 3. Sleeplessness

2. A client reports taking St. John's wort for depression. The client states, "I'm taking the recommended dose, but it seems like if two capsules are good, four would be better!" Which is the most appropriate nursing reply? 1. "Herbal medicines are more likely to cause adverse reactions than are prescription medications." 2. "Increasing the amount of herbal preparations can lead to overdose and toxicity." 3. "The U.S. Food and Drug Administration (FDA) does not regulate herbal remedies; therefore, ingredients are often unknown." 4. "Certain companies are better than others. Always buy a reputable brand."

2. "Increasing the amount of herbal preparations can lead to overdose and toxicity."

14. Which of the following nursing statements best explains to the client the benefits of pet therapy? Select all that apply. 1. "Pet therapy allows the therapist to assess the client's social relationships." 2. "Pet therapy decreases blood pressure." 3. "Pet therapy enhances client mood." 4. "Pet therapy improves sensory functioning." 5. "Pet therapy mitigates the effects of loneliness."

2. "Pet therapy decreases blood pressure." 3. "Pet therapy enhances client mood." 5. "Pet therapy mitigates the effects of loneliness."

3. A child has been diagnosed with autism spectrum disorder (ASD). The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? 1. "Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." 2. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." 3. "Research has shown that the mother appears to play a greater role in the development of this disorder than does the father." 4. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle feed?"

2. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control."

4. A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? 1. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." 2. "Reminiscence therapy encourages members to share significant life memories to promote resolution." 3. "Reminiscence therapy is a social group where members chat about past events and future plans." 4. "Reminiscence therapy encourages members to share positive memories of significant life transitions."

2. "Reminiscence therapy encourages members to share significant life memories to promote resolution."

16. The nurse is teaching the child of an older adult about the psychological changes associated with aging. Which statement made by the nurse is correct? Select all that apply. 1. "All older adults experience decreased blood flow to the brain that can cause loss of long-term memory." 2. "Short-term memory deteriorates with age, which is most likely due to poor sorting strategies in the older adult." 3. "Older people have trouble learning new things, just like the old saying 'you can't teach an old dog new tricks."' 4. "Older people who are well-educated and mentally active do not lose their memory like their peers who aren't as mentally active." 5. "Your parent can still learn new tasks; it just may take a little longer than it used to."

2. "Short-term memory deteriorates with age, which is most likely due to poor sorting strategies in the older adult." 4. "Older people who are well-educated and mentally active do not lose their memory like their peers who aren't as mentally active." 5. "Your parent can still learn new tasks; it just may take a little longer than it used to."

14. A 20-year-old client tells the nurse in the outpatient clinic, "I am so disgusted with myself. For the past month, there are times when I eat everything I can find. I want to vomit it all back up, but I have never been able to." Which is the nurse's best reply? 1. "It's normal to feel depressed after eating so much." 2. "Tell me about relationships with the people in your life." 3. "I am not surprised to hear you feel so disgusted with yourself." 4. "Have you ever been diagnosed with clinical depression?"

2. "Tell me about relationships with the people in your life."

6. A client diagnosed with schizophrenia tells the nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is the correct charting entry to describe this client's statement? 1. "The client is speaking with clang associations." 2. "The client is expressing feelings with a neologism." 3. "The client demonstrates paranoid thinking." 4. "The client is communicating with a word salad."

2. "The client is expressing feelings with a neologism."

8. A client inquires about the practice of therapeutic touch. Which nursing reply best explains the goal of this therapy? 1. "The goal is to improve circulation to the body by deep, circular massage." 2. "The goal is to repattern the body's energy field by the use of rhythmic hand motions." 3. "The goal is to improve breathing by increasing oxygen to the brain and body tissues." 4. "The goal is to decrease blood pressure by body toxin release."

2. "The goal is to repattern the body's energy field by the use of rhythmic hand motions."

3. A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? 1. "I'm glad we discussed this. We'll excuse him from the activity groups." 2. "The groups benefit your father by providing sensory stimulation and reality orientation." 3. "The groups are optional. Only clients at high-functioning levels would benefit." 4. "If your father doesn't go to these activity groups, he will develop dementia."

2. "The groups benefit your father by providing sensory stimulation and reality orientation."

16. A healthy adolescent client with no history of substance abuse presents to the mental health clinic. This client tells the nurse that she has experienced several episodes where she feels like she is watching a movie of herself where she is floating above and watching herself as an outside observer. She asks the nurse what is wrong with her. Which statement made by the nurse is most appropriate? 1. "You have derealization disorder and must be treated for this immediately." 2. "These may be symptoms of depersonalization disorder, but I'm going to suggest you meet with the psychiatrist for a diagnosis." 3. "You must be schizophrenic. I'm going to ask the psychiatrist to run some tests on you." 4. "I wouldn't worry about these symptoms. These are typical for female teenagers who are experiencing hormonal changes."

2. "These may be symptoms of depersonalization disorder, but I'm going to suggest you meet with the psychiatrist for a diagnosis."

21. The nurse has taken report for the evening shift on an adolescent inpatient unit. Which client would the nurse address first? 1. A client diagnosed with ODD being sexually inappropriate with staff 2. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu 3. A client diagnosed with conduct disorder who is demanding special attention from staff 4. A client diagnosed with ADHD who has a history of self-mutilation

2. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu

18. Which adults are most likely to maintain a positive self-concept during the aging process? Select all that apply. 1. A single, successful mid-level manager at a computer company who works 60 hours per week 2. A middle-aged college professor who hosts dinner parties for her students 3. A busy parent of four children who volunteers at a retirement home during her children's school day 4. A 30-something homemaker who struggles with substance abuse 5. A middle-age man who realizes that his only relationships were developed via his work

2. A middle-aged college professor who hosts dinner parties for her students 3. A busy parent of four children who volunteers at a retirement home during her children's school day

18. Which does the Patient Self-Determination Act require? Select all that apply. 1. States must define how and under what circumstances individuals can refuse lifesustaining medical interventions. 2. All health care facilities must advise clients of their rights to refuse treatment. 3. Advance directives are made available to clients on admission. 4. Records of whether a client has an advance directive or designated health care proxy exist.

2. All health care facilities must advise clients of their rights to refuse treatment. 3. Advance directives are made available to clients on admission. 4. Records of whether a client has an advance directive or designated health care proxy

5. A client whose child is diagnosed with terminal breast cancer is constantly crying and depressed. Which type of grieving is she experiencing? 1. Delayed grieving 2. Anticipatory grieving 3. Prolonged grieving 4. Distorted grief

2. Anticipatory grieving

Chapter 28 1. A client exhibits paranoia, bizarre behaviors, neologisms, and delusions of persecution. While eating breakfast in the dayroom, the client starts yelling at others. Which is the nurse's first action? 1. Ensure client is swallowing each dose of medication. 2. Ask other clients to step out of the dayroom. 3. Call the provider for an order to place the client in restraints. 4. Escort the client to a less-stimulating environment.

2. Ask other clients to step out of the dayroom.

8. A child has been recently diagnosed with mild ID. Which information about this diagnosis would the nurse include when teaching the child's mother? 1. Children with mild ID need constant supervision. 2. Children with mild ID develop academic skills up to a sixth-grade level. 3. Children with mild ID appear different from their peers. 4. Children with mild ID have significant sensory-motor impairment.

2. Children with mild ID develop academic skills up to a sixth-grade level.

11. The nurse is counseling a client diagnosed with gender dysphoria. Which characteristic would differentiate this disorder from transvestic disorder? 1. Clients diagnosed with transvestic disorder are dissatisfied with their gender, whereas clients diagnosed with gender dysphoria are not. 2. Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not. 3. Clients diagnosed with gender dysphoria never engage in cross-dressing, whereas clients diagnosed with transvestic disorder do. 4. Clients diagnosed with transvestic disorder never engage in cross-dressing, whereas clients diagnosed with gender dysphoria do.

2. Clients diagnosed with gender dysphoria are dissatisfied with their gender, whereas clients diagnosed with transvestic disorder are not.

20. A client diagnosed with DID has likely been diagnosed with which disorders in the past? Select all that apply. 1. Attention deficit-hyperactivity disorder 2. Depression 3. Bipolar Disorder 4. Epilepsy 5. Oppositional Defiant Disorder 6. Schizophrenia

2. Depression 3. Bipolar Disorder 4. Epilepsy 6. Schizophrenia

9. Which statement accurately describes dissociative fugue? 1. Dissociative fugue is not precipitated by stressful events. 2. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one's past. 3. Dissociative amnesia and dissociative fugue are completely different types of disorders. 4. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

2. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one's past.

21. The nurse is admitting a client to the inpatient psychiatric unit. Which intervention is most appropriate to reduce the client's delusional thinking? 1. Provide evidence to orient the client to reality. 2. Explore the client's feelings about the delusions. 3. Use logical explanations to address the delusions. 4. Encourage the client to provide reasons for the delusions.

2. Explore the client's feelings about the delusions.

5. Which is used as first-line outpatient psychological treatment for adolescents diagnosed with anorexia nervosa? 1. Cognitive-based therapy 2. Family-based therapy 3. Dialectical behavior therapy 4. Individual psychotherapy

2. Family-based therapy

16. The nurse in the eating disorders clinic asks a client diagnosed with bulimia nervosa, "Can you recall a time when you were able to eat without purging?" Which is the most appropriate rationale for the nurse's question? 1. Determine the severity of symptoms. 2. Identify previous coping strategies. 3. Determine triggers for purging episodes. 4. Establish realistic treatment goals.

2. Identify previous coping strategies.

12. The nurse is developing nursing diagnoses for a newly admitted client diagnosed with anorexia nervosa. The client has a BMI of 15.8 kg/m2. Which is the priority nursing diagnosis? 1. Ineffective coping 2. Imbalanced nutrition 3. Obesity 4. Disturbed body image

2. Imbalanced nutrition

17. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of ID? 1. Risk for injury related to (R/T) self-mutilation 2. Impaired social interaction R/T nonadherence to social convention 3. Altered verbal communication R/T delusional thinking 4. Social isolation R/T severely decreased gross motor skills

2. Impaired social interaction R/T non-adherence to social convention

15. The nurse is administering medications to a client experiencing acute psychosis. The client's medication orders include haloperidol 50 mg PO bid; benztropine 1 mg PO daily, and zolpidem 10 mg PO at bedtime daily. The nurse administers benztropine to address which of the following? 1. Tactile hallucinations 2. Involuntary facial movements 3. Psychomotor retardation 4. Pacing back and forth

2. Involuntary facial movements

6. Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? 1. Schizophrenia 2. Major depressive disorder 3. Phobic disorder 4. Dependent personality disorder

2. Major depressive disorder

10. Which nursing intervention would be prioritized when caring for a child diagnosed with ID? 1. Encourage the parents to always prioritize the needs of the child. 2. Modify the child's environment to promote independence and encourage impulse control. 3. Delay extensive diagnostic studies until the child is developmentally mature. 4. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

2. Modify the child's environment to promote independence and encourage impulse control.

16. The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia? 1. Paranoia, anhedonia, and anergia are positive symptoms. 2. Paranoia, neologisms, and echolalia are positive symptoms. 3. Paranoia, anergia, and echolalia are negative symptoms. 4. Paranoia, flat affect, and anhedonia are negative symptoms.

2. Paranoia, neologisms, and echolalia are positive symptoms.

11. A preschool child is admitted to a psychiatric unit with a diagnosis of ASD. To help the child feel more secure on the unit, which intervention would the nurse include in this client's plan of care? 1. Encourage and reward peer contact. 2. Provide consistent caregivers. 3. Provide a variety of safe daily activities. 4. Maintain close physical contact throughout the day.

2. Provide consistent caregivers.

2. Which nursing intervention related to self-care is most appropriate for a teenager diagnosed with moderate ID? 1. Meet all of the client's self-care needs to avoid injury. 2. Provide simple directions and praise client's independent self-care efforts. 3. Avoid interference with the client's self-care efforts to promote autonomy. 4. Encourage family to meet the client's self-care needs to promote bonding.

2. Provide simple directions and praise client's independent self-care efforts.

14. Which behavioral approach would the nurse utilize when caring for children diagnosed with a disruptive behavior disorder? 1. Involving parents in designing and implementing the treatment process. 2. Reinforcing positive actions to encourage repetition of desired behaviors. 3. Providing opportunities to learn appropriate peer interactions. 4. Administering psychotropic medications to improve quality of life.

2. Reinforcing positive actions to encourage repetition of desired behaviors.

20. Which is the priority nursing intervention when caring for a client diagnosed with an eating disorder? 1. Accompany the client to the bathroom. 2. Remain with the client at least 1 hour after meals. 3. Encourage the client to keep a diary of food intake. 4. Discuss feelings and emotions associated with eating.

2. Remain with the client at least 1 hour after meals.

11. Rebecca expresses to the nurse that she feels like she didn't do enough to prevent the loss of her father. Which interventions would the nurse use to address Rebecca's feelings? 1. Encourage Rebecca to examine the guilt and validate the appropriateness of this feeling. 2. Review the circumstances of the loss and the reality that it could not be prevented. 3. Role-play the events, and assist Rebecca with understanding the decisions leading to the loss. 4. Explain that this feeling is a pathological defense that will prevent her from progressing through the stages of grief.

2. Review the circumstances of the loss and the reality that it could not be prevented.

20. The nurse is caring for a college student who started hearing voices, has not attended classes for the past 4 weeks, was yelling accusations at others, and has stopped communicating with family and friends. Which is the nurse's priority nursing diagnosis? 1. Altered thought processes related to (R/T) hearing voices as evidenced by (AEB) increased anxiety 2. Risk for other-directed violence R/T yelling accusations 3. Social isolation R/T paranoia AEB absence from classes 4. Risk for self-directed violence R/T depressed mood

2. Risk for other-directed violence R/T yelling accusations

4. While assessing a client diagnosed with bulimia nervosa, the nurse observes multiple cavities, enamel erosion, and tooth sensitivity. Which best explains the nurse's findings? 1. Electrolyte imbalances 2. Self-induced vomiting 3. Nutritional deficits 4. Dehydration

2. Self-induced vomiting

3. A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis would be prioritized for this client? 1. Risk for situational low self-esteem as evidenced by (AEB) inability to achieve an erection 2. Sexual dysfunction related to (R/T) dysfunctional grieving AEB inability to experience orgasm 3. Social isolation R/T low self-esteem AEB refusing to engage in dating activities 4. Disturbed body image R/T penile flaccidity AEB client statements

2. Sexual dysfunction related to (R/T) dysfunctional grieving AEB inability to experience orgasm

4. The nurse is assessing a client diagnosed with pedophilic disorder. Which statement differentiates this sexual disorder from a sexual dysfunction? 1. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. 2. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. 3. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. 4. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

2. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response.

24. The nurse is obtaining the mental health history of a client diagnosed with schizophrenia. The client's family reports that the client is hearing voices and cannot stay focused on the topic of a discussion. The nurse recognizes the client is demonstrating which symptom? 1. Delusions of reference 2. Tangentiality 3. Neologism 4. Loose associations

2. Tangentiality

7. Which finding is the nurse most likely to assess in a child diagnosed with separation anxiety disorder? 1. The child has a history of antisocial behaviors. 2. The child's mother is diagnosed with an anxiety disorder. 3. The child previously had an extroverted temperament. 4. The child's parents have inconsistent parenting styles.

2. The child's mother is diagnosed with an anxiety disorder.

Chapter 36 1. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kübler-Ross's grief stage of anger? 1. The client registers for an iron-man marathon to be held in 9 months. 2. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him. 3. The client promises God to give up smoking if allowed to live long enough to witness a grandchild's birth. 4. The client gathers family to plan a funeral and make their last wishes known.

2. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him.

8. An elderly, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on the shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate? 1. The client will honestly reveal the nature of the injuries. 2. The client may deny or minimize the injuries. 3. The client may have forgotten what caused the injuries. 4. The client will ask to be placed in a nursing home.

2. The client may deny or minimize the injuries.

9. Which is the most accurate description of the nursing diagnosis of spiritual distress? 1. The client reports no church affiliations. 2. The client struggles to identify meaning and purpose in life. 3. The client reports seeing the spirit of his deceased spouse. 4. The client reports that meditation helps him feel spiritually connected.

2. The client struggles to identify meaning and purpose in life.

3. Which outcome is appropriate when planning care for an inpatient client diagnosed with somatic symptom disorder? 1. The client will admit to fabricating physical symptoms to gain benefits by day 3. 2. The client will list three potential adaptive coping strategies to deal with stress by day 2. 3. The client will comply with medical treatments for physical symptoms by day 3. 4. The client will openly discuss physical symptoms with staff by day 4.

2. The client will list three potential adaptive coping strategies to deal with stress by day 2.

21. The client is an older adult who has worked with the same company as an electrical engineer for several years and has been given an "early out" to retire. Which of the following statements reflects a positive self-identity during this change? Select all that apply. 1. "This is all that I have known my whole life." 2. "I won't know what to do without a routine." 3. "I can use my knowledge to mentor others." 4. "I will be able to spend more quality time with my family." 5. "Good thing I saved for this day; now I can travel."

3. "I can use my knowledge to mentor others." 4. "I will be able to spend more quality time with my family." 5. "Good thing I saved for this day; now I can travel."

8. A client diagnosed with schizophrenia says, "Can't you hear him? The devil keeps telling me I'm going to hell!" Which is the nurse's most appropriate reply? 1. "Did you take your medication this morning?" 2. "You are a good person, and you are not going to hell." 3. "It must be scary to hear that, but I don't hear a voice." 4. "The devil only talks to people who are receptive to his influence."

3. "It must be scary to hear that, but I don't hear a voice."

17. The nurse is providing discharge teaching to an elderly client diagnosed with schizophrenia. The client's medications include an antipsychotic (risperidone) and a beta-adrenergic blocking agent (propranolol). Which statement indicates the nurse understands the combined side effects of these medications? 1. "Concentrate on taking slow, deep, cleansing breaths." 2. "Limit your intake of foods that are high in sugar." 3. "Move slowly when you change from a lying down or sitting position." 4. "Always wear sunscreen and a hat when you are exposed to the sun."

3. "Move slowly when you change from a lying down or sitting position."

Chapter 29 1. Which student statement indicates an understanding regarding dissociative identity disorder (DID)? 1. "I suspect my client inherited this disease from his parent." 2. "It is unlikely my client had a diagnosis of schizophrenia before DID, since the two do not go hand in hand." 3. "My client experiences periods of blackouts, or lost time where he doesn't know what happened during that time frame." 4. "I assume my client has other personalities because he doesn't want to deal with real life."

3. "My client experiences periods of blackouts, or lost time where he doesn't know what happened during that time frame."

10. Which would the nurse recognize as an example of localized amnesia? 1. A client cannot relate any lifetime memories, including personal identity. 2. A client can relate family memories but has no recollection of a particular brother. 3. A client cannot remember events surrounding a fatal car accident. 4. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

3. A client cannot remember events surrounding a fatal car accident.

7. An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm. The client is soaked in urine and has dried fecal matter on the lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? 1. Self-care deficits 2. Alzheimer's dementia 3. Abuse or neglect or both 4. Caregiver role strain

3. Abuse or neglect or both

Chapter 33 1. A client has recently been placed in a long-term care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem? 1. Leave the client alone in the bathroom. 2. Assign a variety of caregivers. 3. Allow the client to choose between two different outfits. 4. Modify the daily schedule often to maintain variety.

3. Allow the client to choose between two different outfits.

10. An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen? 1. Altered cortical and intellectual functioning 2. Altered respiratory and gastrointestinal functioning 3. Altered hepatic and renal functioning 4. Altered endocrine and immune system functioning

3. Altered hepatic and renal functioning

25. A client diagnosed with psychosis asks the nurse to make the voices stop talking so he can go to sleep. Which is the most important nursing intervention? 1. Ask the client whether the voices seem familiar. 2. Guide the client to bed and gently rub their back. 3. Ask the client what the voices are saying. 4. Suggest the client tell the voices to go away.

3. Ask the client what the voices are saying.

11. The clinic nurse is reviewing assessment findings of a client diagnosed with anorexia nervosa. Which of the following indicate that the client requires immediate hospitalization? 1. Body temperature of 98.6ºF 2. Potassium level above 3.5 mmol/L 3. BMI less than 75% of expected 4. Weight less than 90% of expected

3. BMI less than 75% of expected

3. A client with chronic lower back pain states, "My nurse practitioner told me that acupuncture might enhance the effect of the medications and physical therapy prescribed." Which type of therapy is the nurse practitioner recommending? 1. Alternative therapy 2. Physiotherapy 3. Complementary therapy 4. Biopsychosocial therapy

3. Complementary therapy

19. The nurse on the eating disorder unit schedules group therapy sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time? 1. Limit time allotted for meals. 2. Identify maladaptive eating behaviors. 3. Discuss feelings associated with eating behaviors. 4. Focus on regaining control.

3. Discuss feelings associated with eating behaviors.

Chapter 30 1. The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa? 1. Recognize maladaptive eating patterns as defense mechanisms. 2. Promote autonomy and control over eating behaviors. 3. Eliminate emotional components of maladaptive eating patterns. 4. Allow client to establish goals of the treatment plan.

3. Eliminate emotional components of maladaptive eating patterns.

6. An inpatient client is newly diagnosed with DID stemming from severe childhood sexual abuse. Which nursing intervention is the priority? 1. Encourage exploration of sexual abuse. 2. Encourage guided imagery. 3. Establish trust and rapport. 4. Administer antianxiety medications.

3. Establish trust and rapport.

3. The nurse is developing a care plan for a client diagnosed with anorexia nervosa and determines "disturbed body image" is the priority nursing diagnosis. Which is the most appropriate outcome criterion? 1. Achieve and maintain expected body mass index (BMI). 2. Verbalize understanding of maladaptive eating behaviors. 3. Exhibit decreased preoccupation with own appearance. 4. Discuss feelings and emotions associated with eating.

3. Exhibit decreased preoccupation with own appearance.

11. Herbs and plants can be useful in treating a variety of conditions. Which herbal treatment should the nurse determine is appropriate for a client experiencing frequent migraine headaches? 1. St. John's wort combined with an antidepressant 2. Ginger root combined with a beta-blocker 3. Feverfew used according to directions 4. Kava-kava added to a regular diet

3. Feverfew used according to directions

13. The nurse in the outpatient clinic determines the priority nursing diagnosis for a client diagnosed with anorexia nervosa is "imbalanced nutrition: less than body requirements." Which is the most appropriate short-term goal for the client? 1. Demonstrate adaptive eating behaviors. 2. Discuss fears and anxieties. 3. Gain 2 lb per week. 4. Exhibit no signs of malnutrition and dehydration.

3. Gain 2 lb per week.

12. A preschool child diagnosed with ASD has been engaging in constant head-banging behavior. Which nursing intervention is most appropriate? 1. Place client in restraints until the aggression subsides. 2. Sedate the client with neuroleptic medications. 3. Hold client's head steady and apply a helmet. 4. Distract the client with a variety of games and puzzles.

3. Hold client's head steady and apply a helmet.

22. A client states, "The voices keep saying I am evil." Which outcome criteria is most important to include in the client's plan of care? 1. Demonstrates the ability to perceive the environment correctly 2. Uses appropriate verbal communication when interacting with others 3. Identifies factors that increase anxiety and illicit hallucinations 4. Demonstrates the ability to relate satisfactorily to others

3. Identifies factors that increase anxiety and illicit hallucinations

8. A client diagnosed with bulimia nervosa has been receiving CBT at the eating disorders clinics. Which of the following client actions indicates to the nurse that the client is making progress toward using adaptive eating behaviors? 1. Gains 2 lb in 1 week 2. Verbalizes importance of adequate nutrition 3. Identifies feelings associated with desire to binge 4. Takes antidepressant medications as prescribed

3. Identifies feelings associated with desire to binge

27. A care plan for the child with ID states that the child "will attempt to interact with others in the presence of trusted caregiver." This is an example of an outcome criterion for which nursing diagnosis? 1. Impaired verbal communication; short-term goal 2. Impaired verbal communication; long-term goal 3. Impaired social interaction; short-term goal 4. Impaired social interaction; long-term goal

3. Impaired social interaction; short-term goal

7. A lethargic client is diagnosed with major depressive disorder. After taking antidepressant medication for 6 weeks, the symptoms have not resolved. Which nutritional deficiency should the nurse identify as potentially contributing to the client's symptoms? 1. Vitamin A 2. Vitamin C 3. Iron 4. Folic acid

3. Iron

7. A client diagnosed with DID switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? 1. It is a means to attain secondary gain. 2. It is a means to explore feelings of excessive and inappropriate guilt. 3. It serves to isolate painful events so that the primary self is protected. 4. It serves to establish personality boundaries and limit inappropriate impulses.

3. It serves to isolate painful events so that the primary self is protected.

5. A client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention would be the nurse's first priority? 1. Contact the client's psychiatrist. 2. Avoid addressing her attention-seeking behavior. 3. Lead the client back to her room and assist her in choosing appropriate clothing. 4. Restrict the client to her room until visiting hours are over.

3. Lead the client back to her room and assist her in choosing appropriate clothing.

19. Which nursing intervention is the priority when caring for a child diagnosed with conduct disorder? 1. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. 2. Convey unconditional acceptance and positive regard. 3. Recognize escalating aggressive behaviors and intervene before violence occurs. 4. Provide immediate positive feedback for appropriate behaviors.

3. Recognize escalating aggressive behaviors and intervene before violence occurs.

14. The nurse observes that a client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication does the nurse anticipate the provider will prescribe? 1. Benztropine 2. Clonazepam 3. Risperidone 4. Sertraline

3. Risperidone

23. A newly admitted client exhibits symptoms of paranoia and hallucinations. The client's spouse states, "I don't understand. My spouse hasn't hallucinated since the doctor prescribed thioridazine 2 years ago." The nurse recognizes which as the most likely explanation for the recurrence of the client's symptoms? 1. The client has developed tolerance to the medication. 2. The client has been taking the medication with food. 3. The client has not been taking the medication as prescribed. 4. The client has been drinking alcohol with the medication.

3. The client has not been taking the medication as prescribed.

7. The nurse assesses a client as experiencing maladaptive grieving. Which factor confirms the nurse's assessment? 1. The client's spouse died 12 months ago. 2. The client still cries when recalling memories of the deceased. 3. The client reports feelings of worthlessness. 4. The client reports intermittent anxiety.

3. The client reports feelings of worthlessness.

4. In planning care for a child diagnosed with ASD, which is a realistic client outcome? 1. The client will communicate all needs verbally by discharge. 2. The client will participate with peers in a team sport by day 4. 3. The client will establish trust with at least one caregiver by day 5. 4. The client will perform most self-care tasks independently.

3. The client will establish trust with at least one caregiver by day 5.

6. The nurse is working with a client diagnosed with pedophilic disorder. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? 1. The client will verbalize an understanding of the importance of follow-up care. 2. The client will implement several relapse-prevention strategies. 3. The client will identify triggers that lead to inappropriate behaviors. 4. The client will attend aversion therapy groups.

3. The client will identify triggers that lead to inappropriate behaviors.

4. A client has been diagnosed with somatic symptom disorder. As the nurse is talking with this client and her family, which statement suggests primary or secondary gains that the physical symptoms are providing for the client? 1. The family agrees that the client began having physical symptoms after she lost her job. 2. The client states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. 3. The client's mother reports that someone from the family stays with her each night because the physical symptoms are incapacitating. 4. The client states she noticed feeling hotter than usual the last time she had a headache.

3. The client's mother reports that someone from the family stays with her each night because the physical symptoms are incapacitating.

24. A child diagnosed with ADHD is having difficulty completing homework assignments. Which information would the nurse include when teaching the parents about task performance improvement? 1. The parents should isolate the child when completing homework to improve focus. 2. The parents should withhold privileges if homework is not completed within a 2-hour period. 3. The parents should divide the homework task into smaller steps and provide an activity break. 4. The parents should administer an extra dose of methylphenidate prior to homework.

3. The parents should divide the homework task into smaller steps and provide an activity break.

5. The nurse is caring for a client who blinks when the nurse asks a question and coughs when the nurse looks at him. Which condition does the nurse suspect? 1. Oppositional defiant disorder (ODD) 2. ASD 3. Tourette's disorder 4. Conduct disorder

3. Tourette's disorder

9. A client diagnosed with neurocognitive disorder due to Alzheimer's disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication? 1. Discourage attempts at verbal communication. 2. Increase the volume of the nurse's communication responses. 3. Verbalize the nurse's perception of the implied communication. 4. Encourage the client to communicate by writing.

3. Verbalize the nurse's perception of the implied communication.

2. A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should the nurse teach the client? 1. Side effects of medications 2. Deep breathing techniques 3. Ways to make eye contact when communicating 4. Techniques to improve memory and attention

3. Ways to make eye contact when communicating

33. The nurse is caring for a 16-year-old client with ASD who is receiving risperidone for agitation. For which effects would the nurse monitor the client? Select all that apply. 1. Signs of bruising 2. Improved mood 3. Weight gain of 20 lb in 1 month 4. Elevated blood glucose level 5. Uncontrolled jaw movements

3. Weight gain of 20 lb in 1 month 4. Elevated blood glucose level 5. Uncontrolled jaw movements

9. Which statement by the student nurse requires further teaching regarding the sexual response cycle? 1. "During phase 1, the desire to have sex can occur in response to visual stimulation." 2. "In the second phase, sexual arousal and erotic pleasure occur." 3. "During phase 3, sexual tension is released as orgasm is achieved." 4. "Sexual fantasies can stimulate the fourth phase of sexual response."

4. "Sexual fantasies can stimulate the fourth phase of sexual response."

9. Which student statement indicates further instruction is needed regarding developmental characteristics of clients diagnosed with moderate intellectual developmental disorder? 1. "These clients can work in a sheltered workshop setting." 2. "These clients can perform some personal care activities." 3. "These clients may have difficulty relating to peers." 4. "These clients can successfully complete elementary school."

4. "These clients can successfully complete elementary school."

26. A pregnant client is being treated for uncontrolled diabetes and reports to the nurse, "I have two other children, and my diabetes hasn't affected them. I'm sure this baby will be fine too." What percentage of ID cases result in early alterations in embryonic development? 1. 5% 2. 10% 3. 20% 4. 30%

4. 30%

4. A teenager has recently lost a parent. Which grieving behavior would the school nurse expect when assessing this client? 1. Denial of personal mortality 2. Preoccupation with the loss 3. Clinging behaviors and personal insecurity 4. Aggressive and defiant behaviors

4. Aggressive and defiant behaviors

18. Which child is most likely to be diagnosed with ASD? 1. A 5-year-old girl 2. A 6-year-old girl 3. A 7-year-old girl 4. An 8-year-old boy

4. An 8-year-old boy

25. A nursing instructor is teaching about pharmacological treatments for ADHD. Which information about atomoxetine should be included in the lesson plan? 1. Atomoxetine, unlike methylphenidate, is a CNS depressant. 2. When taking atomoxetine, a client should eliminate all red food coloring from the diet. 3. Atomoxetine will be a lifelong intervention for clients diagnosed with this disorder. 4. Atomoxetine, unlike methylphenidate, is a selective norepinephrine reuptake inhibitor (SNRI).

4. Atomoxetine, unlike methylphenidate, is a selective norepinephrine reuptake inhibitor (SNRI).

10. Bob Taylor's home was recently destroyed in a fire. Margaret Smith is 35 years old and has just learned that she must have a hysterectomy. Which scenario will most likely trigger a grief response? 1. Taylor's home being destroyed by fire. 2. Smith's pending hysterectomy. 3. Neither scenario by itself could trigger a grief response. 4. Both scenarios could trigger individual grief responses.

4. Both scenarios could trigger individual grief responses.

12. The nurse understands that when a practitioner corrects subluxation by manipulating the vertebrae of the spinal column, the practitioner is employing which therapy? 1. Allopathic therapy 2. Therapeutic touch therapy 3. Massage therapy 4. Chiropractic therapy

4. Chiropractic therapy

5. The nurse is assessing a client diagnosed with schizophrenia and asks, "Do you ever get messages through things, like the television or microwave?" Which symptom of schizophrenia is the nurse assessing for? 1. Illusions 2. Circumstantiality 3. Hallucinations 4. Delusions of reference

4. Delusions of reference

29. The nurse notes elevated levels of prolactin while reviewing the laboratory results of a client diagnosed with schizophrenia. Which symptoms should the nurse expect to assess? Select all that apply. 1. Apathy 2. Social withdrawal 3. Anhedonia 4. Galactorrhea 5. Gynecomastia

4. Galactorrhea 5. Gynecomastia

15. An experienced nurse on the eating disorders unit is explaining to a newly hired nurse the rationale for setting limits with clients. Which is the nurse's most appropriate explanation? 1. It encourages awareness of emotional issues. 2. It encourages understanding of behavior modification plan. 3. It promotes sense of control unhealthy eating behaviors. 4. It prevents power struggles with staff.

4. It prevents power struggles with staff.

28. Sophie is 11 years old and has a diagnosis of ADHD. Her parents report and provide documentation from her teachers that Sophie is distracted easily and is unable to complete classroom activities, even in the presence of minimal stimulation. A nursing diagnosis of noncompliance with task expectations has been determined, with a shortterm goal that Sophie will participate in and cooperate during therapeutic activities. Which nursing intervention is most appropriate? 1. Establish goals that allow Sophie to complete part of the task, rewarding each step completion with a break for physical activity. 2. Ask Sophie to repeat instructions to you. 3. Provide assistance on a one-to-one basis, beginning with simple, concrete instructions. 4. Provide an environment for task efforts that is as free of distractions as possible.

4. Provide an environment for task efforts that is as free of distractions as possible.

10. The nurse notices a client is becoming very agitated. Which nursing intervention is most appropriate? 1. Instruct the client to watch television in the dayroom. 2. Maintain continuous eye contact when talking to the client. 3. Hold the client's hand while walking in the hallway. 4. Provide the client with adequate personal space.

4. Provide the client with adequate personal space.

13. A nurse is conducting a class on fall prevention at a local senior center. In relationship to the slowed cognitive processing of advanced age, which teaching modification would be most appropriate for the nurse to implement? 1. Encouraging the clients to use hearing aids, if needed 2. Avoiding overarticulation 3. Minimizing distractive stimuli 4. Providing more time for client feedback

4. Providing more time for client feedback

14. A client diagnosed with glaucoma is being discharged to an assisted-living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client? 1. Repeat information at least four times. 2. Present discharge teaching to the client's spouse. 3. Use a taped message that can be repeated as needed. 4. Reinforce critical content by providing large-print handouts.

4. Reinforce critical content by providing large-print handouts.

Chapter 32 1. Which developmental characteristic should the nurse identify as typical of a client diagnosed with severe intellectual disability (ID)? 1. The client can perform some self-care activities independently. 2. The client has advanced speech development. 3. Other than possible coordination problems, the client's psychomotor skills are not affected. 4. The client communicates wants and needs by "acting out" behaviors.

4. The client communicates wants and needs by "acting out" behaviors.

32. The nurse would recognize which of the following as contributing factors to a client's development of ADHD? Select all that apply. 1. The client's parent was a smoker. 2. The client was born 7 weeks premature. 3. The client is lactose intolerant. 4. The client has a sibling diagnosed with ADHD. 5. The client has been diagnosed with dyslexia.

4. The client has a sibling diagnosed with ADHD.

19. The nurse is reviewing the provider's orders for a client experiencing acute psychosis. The client's family tells the nurse the client has allergies to penicillin, prochlorperazine, and bee stings. Which medication order should the nurse question? 1. Haloperidol 5 mg intramuscularly every 4 hours as needed 2. Clozapine 150 mg PO twice daily 3. Risperidone 2 mg PO twice daily 4. Thioridazine 100 mg PO three times daily

4. Thioridazine 100 mg PO three times daily

8. A client is diagnosed with DID. Which statement describes the primary goal of therapy for this client? 1. To recover memories and improve thinking patterns 2. To prevent social isolation 3. To decrease anxiety and the need for secondary gain 4. To collaborate among subpersonalities to improve functioning

4. To collaborate among subpersonalities to improve functioning

7. When planning care for a client diagnosed with female sexual arousal disorder, which would the nurse document as an expected outcome of sensate focus exercises? 1. To initiate immediate orgasm 2. To reduce anxiety by eliminating physical touch 3. To focus on touching breasts and genitals 4. To reduce goal-oriented demands of intercourse

4. To reduce goal-oriented demands of intercourse

20. The nurse is assessing a 14-year-old client who is receiving aripiprazole. Which side effect would be of most concern to the nurse? 1. Dizziness 2. Headache 3. Nausea 4. Tremor

4. Tremor

11. Which nursing action is most appropriate to establish trust with a suspicious client? 1. Maintain consistent staff assignments. 2. Reinforce and focus on reality. 3. Maintain low environmental stimuli. 4. Use a passive communication approach.

4. Use a passive communication approach.

George Engel Stages of Grief

Stage I: Shock and Disbelief Stage II: Developing awareness Stage III: Restitution Stage IV: Resolution of the loss Stage V: Recovery