NUR123 Exam 3

The mother of a 3-year-old boy just diagnosed with autism spectrum is tearful and states, "The doctor said we need to start therapy right away. I just don't understand how helpful it will be—he's only 3 years old!" What response should the nurse provide to the mother's statement? a. "If you have questions, its best to ask the doctor." c. "You are right, 3 years old is very young to start therapy, but it will make you feel better to be doing something." d. "If your child starts therapy now, he will be able to stop therapy sooner."

b. "Starting him on treatment now gives your child a much greater chance for a productive life."

Which statement factually describes the act of suicide? a. Suicide is the leading cause of death in the United States. b. A client with schizophrenia is at great risk for attempting suicide. c. More women than men commit suicide. d. Religious Jews have the lowest suicide rate.

b. A client with schizophrenia is at great risk for attempting suicide.

Which room placement would be best for a client experiencing a manic episode? a. A shared room with a client with dementia b. A single room near the nurses' station c. A shared room away from the unit entrance d. A single room near the unit activities area

b. A single room near the nurses' station

According to Freud, a client experiencing dysfunction of the conscious as part of the mind will have problems with which aspect of memory? a. Recent memory b. All memories c. Painful memories d. Long-term memory

b. All memories

A 16-year-old patient being treated for anorexia, has been prescribed medication to reduce compulsive behaviors regarding food now that ideal weight has been reached. Which class of medication is prescribed for this specific issue associated with eating disorders? a. Mood stabilizers b. Antidepressants c. Atypical antipsychotics d. Anxiolytics

b. Antidepressants

As an adult, a client who has been diagnosed with childhood-onset conduct disorder is at high risk for developing which comorbid disorder? a. Obsessive-compulsive disorder b. Antipersonality disorder c. Kleptomania d. Depression

b. Antipersonality disorder

Assessment for oppositional defiant disorder should include which interventions? a. Assessing the history, frequency, and triggers for violent outbursts b. Assessing issues that result in power struggles and triggers for outbursts c. Assessing moral development, belief system, and spirituality for the ability to understand the impact of hurtful behavior on others, to empathize with others, and to feel remorse d. Assessing sibling birth order to understand the dynamics of family interaction

b. Assessing issues that result in power struggles and triggers for outbursts

Which social behavior is often a result of a child having been exposed to some form of abuse? a. Speech disorders b. Bullying others c. Eating disorders d. Delayed motor skills

b. Bullying others

Which behavior consistently demonstrated by a child is a predictor of future antisocial personality disorder in adults? a. Sadness b. Callousness c. Remorse d. Guilt

b. Callousness

The mother of a 6-year-old child expresses concern over the child's frequent temper outbursts. He deals with any frustration by bullying and hitting and seldom shows any remorse for his actions. The nurse who gathers this data will note that the child's behaviors are most consistent with which diagnosis? a. Oppositional defiant disorder b. Conduct disorder c. Attention deficit hyperactivity disorder (ADHD) d. Social phobia

b. Conduct disorder

Schizophrenia is best characterized as presenting which personality trait? a. Multiple b. Deteriorating c. Split d. Ambivalent

b. Deteriorating

During a family therapy session the mother says to her daughter, "I would like to know why you took the piece of pie that was left after dinner last night. You knew I wanted it." Later the father tells his daughter, "I know exactly why you did that." The nurse therapist should consider the possibility that the family is demonstrating which boundary issue a. Inflexible b. Diffused c. Disengaged d. Clear

b. Diffused

Which client problem would be most suited to the use of interpersonal therapy? a. Disturbed sensory perception b. Dysfunctional grieving c. Impaired sensory perception d. Medication noncompliance

b. Dysfunctional grieving

According to current theory, which statement regarding eating disorders is accurate? a. Eating disorders are rarely comorbid with other mental health disorders. b. Eating disorders are possibly influenced by sociocultural factors. c. Eating disorders are frequently misdiagnosed. d. Eating disorders are psychotic disorders in which patients experience body dysmorphic disorder.

b. Eating disorders are possibly influenced by sociocultural factors.

A 17-year-old client is admitted to the psychiatric unit after threatening his mother during an argument and is diagnosed with conduct disorder. Which of the following would be an appropriate short-term outcome for this client? a. Maintains self-control during hospitalization b. Expresses feelings c. Mother will improve communication skills to interact with Eli. d. Engages in appropriate coping skills to manage stressors

b. Expresses feelings

Which assessment tool is highly effective in uncovering multigenerational issues in a family? a. Focused interview b. Genogram c. Family function checklist d. Family assessment device

b. Genogram

A client diagnosed with disorganized schizophrenia would have greatest difficulty with the nursing intervention? a. Providing nutritional supplements b. Giving multistep directions c. Using concrete language d. Interacting with a neutral attitude

b. Giving multistep directions

A 31-year-old client admitted with acute mania tells the staff and the other clients that he is on a secret mission for the President of the United States. He states, "I am the only one he trusts, because I am the best!" What term will the nurse use when documenting this behavior? a. Flight of ideas b. Grandiosity c. Rapid cycling d. Unpredictability

b. Grandiosity

The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed? a. Has serum potassium level of 3 mEq/L or greater. b. Has systolic blood pressure less than 90 mm Hg. c. Weighs 10% below ideal body weight. d. Has a heart rate less than 60 beats/min.

b. Has systolic blood pressure less than 90 mm Hg.

Unit practice requires inspection of all items being brought onto the unit by visitors. How can this be most effectively done? a. Asking all visitors to report to the nurse's station before visiting a client. b. Having a staff member sit at the door and check packages as visitors enter. c. Asking clients to give staff any unsafe item that might have been left by a visitor. d. Having a staff member make frequent rounds during visiting hours to inspect gifts.

b. Having a staff member sit at the door and check packages as visitors enter.

When treating impulse control disorders, psychodynamic psychotherapy is directed toward which goal? a. Helping the client replace the rage with acceptable alternative feelings b. Identifying the triggers of the rage c. Mastering relaxation techniques d. Teaching the client self-distracting techniques

b. Identifying the triggers of the rage

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

b. Imbalanced nutrition: less than body requirements

A student nurse on the psychiatric unit expresses being uncomfortable discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? a. "If I were you, I'd ask the health provider to talk to the patient about that subject." b. "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." c. "Actually, it's a myth that asking about suicide puts ideas into someone's head." d. "You are right; however, because of professional liability, we have to ask that question."

c. "Actually, it's a myth that asking about suicide puts ideas into someone's head."

A 9-year-old patient has been diagnosed with an intellectual development disorder (IDD). Which assessment findings support this diagnosis? (Select all that apply.) a. Is capable of providing effective oral self-care b. Enjoy interacting with developmentally similar peers c. Physically lashes out when frustrated d. Reads below age level e. Unable to explain the phrase, "Raining cats and dogs"

c, d, e c. Physically lashes out when frustrated d. Reads below age level e. Unable to explain the phrase, "Raining cats and dogs"

A client prescribed a monoamine oxidase inhibitor (MOA) has a pass to go out to lunch. Given a choice of the following entrees, what can the client safely eat? a. kielbasa and sauerkraut. b. avocado salad plate. c. fruit and cottage cheese plate. d. liver and onion sandwich.

c. fruit and cottage cheese plate.

Which is the greatest protective factor against the risk of suicide? a. One or more previous suicide attempts b. A cultural belief that suicide is a shameful resolution for a dilemma c. A sense of responsibility to family d. Fear of dying

c. A sense of responsibility to family

When the clinician mentions that a client has anhedonia, the nurse can expect that the client will demonstrate what behavior? a. Difficulty with tasks requiring fine motor skills b. A weight loss from anorexia c. No pleasure from previously enjoyed activities d. Poor retention of recent events

c. No pleasure from previously enjoyed activities

A client on one-to-one supervision at arm's length indicates a need to go to the bathroom but reports, "I cannot 'go' with you standing there." How should the nurse respond to the client's concern? a. "I understand" and allow the client to close the door. b. Keep the door open, but step to the side out of the client's view. c. "For your safety I can be no more than an arm's length away." d. Leave the client's room and wait outside in the hall.

c. "For your safety I can be no more than an arm's length away."

A 38-year-old client is admitted with major depression. Which statement made by the client alerts the nurse to a common accompaniment to depression? a. "I still pray and read my Bible every day." b. "I've heard others say that depression is a sign of weakness." c. "I still feel bad about my sister dying of cancer. I should have done more for her!" d. "My mother wants to move in with me, but I want to independent."

c. "I still feel bad about my sister dying of cancer. I should have done more for her!"

A client diagnosed with paranoid schizophrenia refuses food, stating the voices are saying the food is contaminated and deadly. Which response should the nurse provide to this client statement? a. "You are safe here in the hospital; nothing bad will happen to you." b. "The voices are wrong about the hospital food. It is not contaminated." c. "I understand that the voices are very real to you, but I do not hear them." d. "Other people are eating the food, and nothing is happening to them."

c. "I understand that the voices are very real to you, but I do not hear them."

When a client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me," what would be an appropriate response for the nurse to make? a. "I do not believe I understand the word volmers. Tell me more about them." b. "Why do you think someone, or something is going to harm you?" c. "It must be frightening to think something is going to harm you." d. "You are safe here. This is a locked unit, and no one can get in."

c. "It must be frightening to think something is going to harm you."

A cognitive therapist would help a client restructure the thought "I am stupid!" to which statement? a. "I am not as smart as others." b. "Things like this should not happen to anyone." c. "What I did was stupid." d. "Things usually go wrong for me."

c. "What I did was stupid."

Which child is demonstrating behaviors that support a diagnosis of adolescent onset conduct disorder? a. A 9-year-old male who smokes half a pack of cigarettes a day b. A 9-year-old female who engages in sexually provocative behaviors c. A 12-year-old male who steals a bicycle as a gang initiation d. A 12-year-old female who regularly bullies her younger siblings

c. A 12-year-old male who steals a bicycle as a gang initiation

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? a. Amitriptyline is very expensive, so the client may have to buy fewer at a time. b. The health care provider wants to see whether any side effects occur within the first week of administration. c. Amitriptyline is lethal in overdose. d. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness.

c. Amitriptyline is lethal in overdose.

Which of the following classifications of medication may be prescribed in intermittent explosive disorder? a. Psychostimulants b. Antianxiety agents such as benzodiazepines c. Anticonvulsants d. Monoamine oxidase (MAO) inhibitors

c. Anticonvulsants

The nurse can expect a client demonstrating typical manic behavior to be attired in clothing that includes with characteristics? a. Ill-fitted and ragged b. Dark colored and modest c. Colorful and inappropriate d. Compulsively neat and clean

c. Colorful and inappropriate

When a child demonstrates a temperament that prompts the mother to say, "She is just so different from me; I just can't seem to connect with her." The nurse should plan to provide which intervention? a. Educate the father regarding signs that the child is being physically abused. b. Encourage the mother to consider attending parenting classes. c. Counsel the mother regarding ways to better bond with her child. d. Suggest that the child's father become her primary caregiver.

c. Counsel the mother regarding ways to better bond with her child.

Freud believed that individuals cope with anxiety by implementing which mechanism? a. The superego b. Security operations c. Defense mechanisms d. Cognitive distortions

c. Defense mechanisms

What statement about the comorbidity of depression is accurate? a. Substance abuse and depression are seldom seen as comorbid disorders. b. Depression most often exists in an individual as a single entity. c. Depression is commonly seen in individuals with medical disorders. d. Depression may coexist with other disorders but is rarely seen with schizophrenia.

c. Depression is commonly seen in individuals with medical disorders.

The nurse is planning care for a 14-year-old. The nurse demonstrates an understanding of the developmental task appropriate for this client by providing which experience? a. Spending one-on-one time with staff to establish trust b. Assign them to help clean up the dayroom to develop a sense of industry c. Encouraging them to talk about their school plans to help achieve identity d. Providing them with the opportunity to select which unit activities they will participate in to gain autonomy

c. Encouraging them to talk about their school plans to help achieve identity

A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." What term should the nurse use to identify this behavior? a. Limit testing b. Flight of ideas c. Grandiosity d. Distractibility

c. Grandiosity

Which of the following symptoms would alert a healthcare provider to a possible diagnosis of schizophrenia in a 22-year-old male client? a. Withdrawal from college because of failing grades b. Chaotic and dysfunctional relationships with his family and peers c. Hearing voices telling him to hurt his roommate d. Excessive sleeping with disturbing dreams

c. Hearing voices telling him to hurt his roommate

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

c. Hypokalemia

Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? a. Deficient fluid volume related to abnormal eating habits b. Chronic loss self-esteem related to excessive negative feedback c. Impaired social interaction related to difficulty maintaining relationships d. Anxiety related to nightmares and repetitive activities

c. Impaired social interaction related to difficulty maintaining relationships

A nurse is providing care to a 28-year-old client diagnosed with bipolar disorder who was admitted in a manic state. According to Maslow's Hierarchy of Needs theory, the nurse should identify which client symptom as having priority? a. Rapid, pressured speech b. Grandiose thoughts c. Lack of sleep d. Hyperactive behavior

c. Lack of sleep

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? a. Discounting positive attributes b. Catatonia c. Learned helplessness d. Self-blame

c. Learned helplessness

What is the first-line drug used to treat mania? a. Carbamazepine b. Clonazepam c. Lithium carbonate d. Lamotrigine

c. Lithium carbonate

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

c. Maintaining a normal weight

Beck's cognitive theory suggests that the etiology of depression is related to what factor? a. Serotonin circuit dysfunction b. Sleep abnormalities c. Negative processing of information d. S belief that one has no control over outcomes

c. Negative processing of information

The nurse is planning long-term goals for a 17-year-old male client recently diagnosed with schizophrenia. Which statement should serve as the basis for the goal-setting process? a. If treated quickly following diagnosis, schizophrenia can be cured. b. Schizophrenia can be managed by receiving treatment only at the time of acute exacerbations. c. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability. d. If patients with schizophrenia stay on their drug regimen, they usually lead fully productive lives with no further symptoms.

c. Patients with schizophrenia often do not fully respond to treatment and have residual symptoms and varying degrees of disability.

Which statement is true regarding culture and protective factors against suicide? a. Asian Americans have the highest rates of suicide. b. American Indians and Pacific Islanders have the lowest rates of suicide. c. Religion and the importance of family are protective factors for Hispanic Americans. d. Older women have the highest risk for suicide among African Americans.

c. Religion and the importance of family are protective factors for Hispanic Americans.

Which factor can reduce the vulnerability of a child to etiological influences predisposing to the development of psychopathology? a. Child abuse b. Malnutrition c. Resilience d. Having a depressed parent

c. Resilience

A client states, "I will always be alone because nobody could ever love me." The nurse recognizes that the client is expressing what cognitive-behavioral concept? a. Actualization b. Aversion c. Schema d. Emotional consequence

c. Schema

The nursing diagnosis Risk for self-directed violence has been added to the care plan of a suicidal client. Which is the most appropriate short-term goal for this diagnosis? a. Be able to name three personal strengths. b. Will reclaim any prized possessions that were given away. c. Seek help when feeling self-destructive. d. Consistently participate in a self-help group.

c. Seek help when feeling self-destructive.

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide? a. Acetylcholine b. Dopamine c. Serotonin d. γ-Amino-butyric acid

c. Serotonin

Which theorist is associated with behavioral therapy? a. Sullivan b. Peplau c. Skinner d. Freud

c. Skinner

A client has reached the maintenance phase of schizophrenia. What is the appropriate clinical planning focus for this client? a. Safety and crisis intervention b. Acute symptom stabilization c. Social, vocational, and self-care skills d. Stress and vulnerability assessment

c. Social, vocational, and self-care skills

Pyromania, a behavior associated with impulse control disorders, causes an individual to engage in what behavior? a. Self-mutilate b. Directing anger toward others c. Starting fires d. Stealing for thrill

c. Starting fires

Which of the following is true of the relationship between bipolar disorder and suicide? a. Clients need to be monitored only in the depressed phase because this is when suicides occur. b. As long as clients with bipolar disorder adhere to their medication regimen, there is little risk for suicide. c. Suicide is a serious risk those diagnosed with bipolar disorder commit suicide. d. Clients with bipolar disorder are not considered high risk for suicide.

c. Suicide is a serious risk those diagnosed with bipolar disorder commit suicide.

Tara and Aaron are twins who are both diagnosed with schizophrenia. Aaron was diagnosed at 23 years old and Tara at 31 years old. Based on your knowledge of early and late onset of schizophrenia, which of the following is true? a. Tara will experience more positive signs of schizophrenia such as hallucinations. b. Tara and Aaron have the same expectation of a poor long-term prognosis. c. Tara has a better chance for positive outcomes because of later onset. d. Aaron will be more likely to hold a job and live a productive life.

c. Tara has a better chance for positive outcomes because of later onset.

The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention? a. Stressing the need to suppress overt conflict within the family b. Encouraging the family to use their usual social behaviors at meals c. Teaching the family about the disorder and the client's behaviors d. Urging the family to demonstrate greater caring for the client

c. Teaching the family about the disorder and the client's behaviors

Which statement is true about the characteristics of the oppositional defiant child? a. Girls display more blaming than do boys. b. The defiance is generally directed toward parents and siblings. c. These behaviors are a predictor of future mental health disorders. d. Arguing tends to be more prevalent in boys.

c. These behaviors are a predictor of future mental health disorders.

At what point would the nurse expect a family to demonstrate the greatest dislocation in the family life cycle? a. When the couple renegotiates the marital system as a dyad b. When the couple is deciding whether to have children c. When a member is diagnosed with multiple sclerosis d. When the first child enters school

c. When a member is diagnosed with multiple sclerosis

An acute phase nursing intervention aimed at reducing hyperactivity is demonstrated by which intervention? a. Directing unit activities b. Orienting a new client to the unit c. Writing in a diary d. Exercising in the gym

c. Writing in a diary

A client diagnosed with paranoid schizophrenia tells the nurse, "I have to get away. The volmers are coming to execute me." The term "volmers" can be assessed as what? a. blocking. b. a delusion. c. a neologism. d. clang association.

c. a neologism.

Effective care of a client suspected of experiencing bulimia nervosa calls for the nurse to perform which assessment? a. body fat analysis. b. a range of motion assessment. c. inspection of the oral cavity. d. inspection of body cavities.

c. inspection of the oral cavity.

A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following manifestations should the nurse assess? a. impulsive behavior b. somatic problems c. repetitive counting d. destructiveness

c. repetitive counting

What are the foundational concerns regarding the use of restraint and seclusion when providing care to children? (Select all that apply.) a. Parents may initiate a lawsuit if injury occurs. b. Staff tends to be undertrained in use of restraints in children. c. Staff have conflicted feelings leading to ineffectiveness. d. The principle of least restrictive intervention is a primary concern. e. Research suggests both are psychologically and physically harmful.

d, e d. The principle of least restrictive intervention is a primary concern. e. Research suggests both are psychologically and physically harmful.

Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? a. Do not reweigh client when client requests. b. Weigh 2 times daily first week, then three times weekly. c. Permit no oral intake before weighing. d. Weigh fully clothed before breakfast.

d. Weigh fully clothed before breakfast.

Question 6 of 7 Dysthymia cannot be diagnosed unless it has existed for what period of time? a. At least 6 months b. At least 1 year c. At least 3 months d. At least 2 years

d. At least 2 years

Assessment of the thought processes of a client diagnosed with depression is most likely to reveal what characteristic? a. Sexual preoccupation b. Good memory and concentration c. Delusions of persecution d. Self-deprecating ideation

d. Self-deprecating ideation

A nurse in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching? a. "Below-average intellectual functioning is associated with ADHD" b. "Behaviors associated with ADHD are present prior to age 3" c. "This disorder is characterized by agurmentativeness" d. "Because of this disorder, your child is at an increased riks for injury"

d. "Because of this disorder, your child is at an increased riks for injury"

When working with a client demonstrating impulse control disorders, which nursing interventions have initial priority? (Select all that apply.) a. Establishing a therapeutic nurse-client relationship b. Setting and enforcing limits c. Confronting the client concerning the disruptive behavior d. Presenting appropriate expectations e. Providing a safe environment

a, b, d, e a. Establishing a therapeutic nurse-client relationship b. Setting and enforcing limits d. Presenting appropriate expectations e. Providing a safe environment

4. In addition to impaired nutritional status: less than body requirements, which nursing diagnoses will the nurse identify? Select all that apply. a. Disturbed body image b. Risk for powerlessness c. Risk for eye infection d. Fluid imbalance e. Impaired active range of motion f. Impaired cardiac output g. Chronic low self-esteem

a, b, d, f, g a. Disturbed body image b. Risk for powerlessness d. Fluid imbalance f. Impaired cardiac output g. Chronic low self-esteem

Which of the following statements are true regarding childhood-onset conduct disorder? (Select all that apply.) a. It is characterized by disregard for the rights of others. b. It is more commonly diagnosed in males. c. It is usually outgrown by early adulthood. d. It is characterized by feelings of remorse and regret. e. Those with conduct disorder rationalize their aggressive behaviors. f. It is usually diagnosed in late teen years.

a, b, e a. It is characterized by disregard for the rights of others. b. It is more commonly diagnosed in males. e. Those with conduct disorder rationalize their aggressive behaviors.

4. Given these improvements, identify which actions listed in the left column should be included in the plan of care. Select all that apply. a. Explain why adherence to treatment is essential. b. Assess for akathisia. If present, treat with anti-EPS medications as prescribed c. Connect client with peer-led services in her community d. Treat client for orthostatic hypotension. e. Help client identify and anticipate events that trigger anxiety and hallucinations. f. Involve client in NAMI meetings to engage with peers who recovered from anosognosia g. Make rounds at unpredictable intervals

a, b, e, g a. Explain b. Assess e. Help g. Make

3. Place a checkmark next to assessment data that supports the health care provider's diagnosis of anorexia nervosa. Select all that apply. a. Pushing food around plate b. Use of St. John's wort as a supplement c. Lanugo on the back d. Rigorous exercise regimen e. Pica f. Grandiosity

a, c, d a. Pushing food around plate c. Lanugo on the back d. Rigorous exercise regimen

What is the focus of the SAFE-T assessment tool? (Select all that apply.) a. Identify level of suicidal risk. b. Introduce antidepressant medication therapy c. Stress collaboration with the client d. Facilitate hospitalization. e. Development of client focused treatment.

a, c, e a. Identify level of suicidal risk. c. Stress collaboration with the client e. Development of client focused treatment.

A nurse is providing teaching to an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? Select the 3 that apply: a. yellowing skin b. increased appetite c. malaise d. somnolence e. fever

a, c, e yellowing skin, malaise, fever

Which of the following describe the symptoms of the manic phase of bipolar disorder? (Select all that apply.) a. Distractibility b. Low self-esteem c. Excessive energy d. Withdrawal from environment e. Racing thoughts f. Purposeless movement g. Pressured speech h. Fatigue and increased sleep

a, c, e, f, g a. Distractibility c. Excessive energy e. Racing thoughts f. Purposeless movement g. Pressured speech

Which comorbid conditions are commonly associated with oppositional defiant disorder? (Select all that apply.) a. Depression b. Conversion disorder c. Substance abuse d. Attention deficit hyperactivity disorder (ADHD) e. Anxiety

a, d, e a. Depression d. Attention deficit hyperactivity disorder (ADHD) e. Anxiety

3. Identify the assessment findings that will require immediate follow-up by the nurse. Select all that apply. a. Resting heart rate of 102 b. History of migraines c. History of childhood ADHD d. Grandiosity e. BP of 142/90 f. Sleep deprivation g. Paranoia h. Irresponsible financial choices

a, e, f, g a. Resting heart rate of 102 e. BP of 142/90 f. Sleep deprivation g. Paranoia

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with which term? a. Psychomotor agitation b. Senile dementia c. Central serotonin syndrome d. Hypertensive crisis

a. Psychomotor agitation

The nurse wants to assess a family's rational patterns by creating their genogram. Which statement best describes the purpose of such an analysis? a. "A genogram will help me see your family structure, history, and current functioning." b. "A genogram is a tool used for deciding on the best type of therapy for your family." c. "A genogram will assess risk for mental illness in future generations." d. "A genogram will help us determine the cause of Jeremy's schizophrenia."

a. "A genogram will help me see your family structure, history, and current functioning."

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? a. "Depression is seen in people of all ages, from childhood to old age." b. "Depression is most often seen among the middle adult age group." c. "The age of onset for most depressive episodes is given as 18 years." d. "That is a good observation. Depression does mostly strike people older than 50 years."

a. "Depression is seen in people of all ages, from childhood to old age."

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

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

A child diagnosed with attention deficit hyperactivity disorder (ADHD) is reprimanded for taking the nurse's pen without asking first. He responds by shouting, "You don't like me! You won't let me have anything, even a pen!" The nurse is most therapeutic when responding with which statement? a. "I do like you, but I don't like it when you grab my pen." b. "You must ask for permission before taking someone else's things." c. "Liking you has nothing to do with whether I will loan you my pen." d. "It sounds as though you are feeling helpless and insecure."

a. "I do like you, but I don't like it when you grab my pen."

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? a. "I think things will be better soon." b. "I don't have a good support system, but I am planning on joining a recovery group." c. "I know a lot of people care about me and want me to get better." d. "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself."

a. "I think things will be better soon."

Consider both Sullivan's term security operations and Freud's term defense mechanisms. Which statement suggests that the client's specialized treatment goal has been successfully met? a. "I'm experiencing much less anxiety about school now." b. "I know that I'm not the only person who has a difficult time in school." c. "Going back to school is hard and I'll need support." d. "I really think I can succeed in school now."

a. "I'm experiencing much less anxiety about school now."

The nurse is working with a client experiencing depression stemming from low self-esteem. The client is distrustful of unit staff and "just wants to go home." Initially what is the nurse's priority? a. Making the client feel physically and emotionally safe b. Teaching the client effective coping skills c. Identifying the client's positive traits d. Focusing on preparing the client for a speedy discharge

a. Making the client feel physically and emotionally safe

Which suicide prevention intervention that has the greatest impact on a client's safety? a. One-on-one observation by the staff. b. Restricting the client from potentially dangerous areas of the unit. c. Removal of personal items that might prove harmful. d. Educating visitors about potentially dangerous gifts.

a. One-on-one observation by the staff.

The most common course of schizophrenia is an initial episode followed by what course of events? a. Recurrent acute exacerbations and deterioration b. Continuous deterioration c. Recurrent acute exacerbations d. Complete recovery

a. Recurrent acute exacerbations and deterioration

A nurse is caring for a school age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? a. Remove the patch each day after 9 hours b. Apply the transdermal patch to the anterior waist area c. Apply the patch once daily at bedtime d. Place the patch carefully in a trash can after removal

a. Remove the patch each day after 9 hours

At the first therapy session the family's father tells the therapist that "We wouldn't have to be here if our younger son wasn't such a brat. He seems so different from our other son. We never had difficulty with him misbehaving." The other sibling offers "He gets upset pretty easily." The nurse should suspect that the younger son is the focus of which family dynamic behavior? a. Scapegoating b. Boundaries resisting c. Differentiation d. Multigenerational transition.

a. Scapegoating

A 5-year-old who consistently omits the sound for 'r' and 's' when speaking is demonstrating which type of disorder? a. Speech b. Specific learning c. Social communication d. Language

a. Speech

A 26-year-old client diagnosed with schizophrenia is having difficulty adjusting to the community after hospitalization. His family is dismayed by his poor hygiene and avolition. Which intervention should the nurse suggest? a. The client attending a psychoeducational group b. Encourage the family to ignore all symptoms except delusions. c. Close supervision of the client by the family d. Suggest group home living for the client in order to avoid family burnout.

a. The client attending a psychoeducational group

The client disagrees that her husband should seek a promotion since it will require the family to move. After she discusses the situation with their 12-year-old, the child tells her father she does not want to move. The client has engaged in which form of dysfunction family dynamics? a. Triangulation b. Diffuse boundaries c. Enmeshment d. A double bind

a. Triangulation

The nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following? a. manipulation b. placation c. blaming d. distraction

a. manipulation

A child diagnosed with autism will demonstrate impaired development in which area? a. playing with other children b. swallowing and chewing c. Adhering to routines d. eye-hand coordination

a. playing with other children

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? a. "Is this part of the reason you think no one likes you?" b. "Let's look at what you just said that you can 'never do anything right.'" c. "Tell me what things you think you are not able to do correctly." d. "That is the most unrealistic thing I have ever heard."

b. "Let's look at what you just said that you can 'never do anything right.'"

The parent of an adolescent diagnosed with mental illness asks the nurse, "Why do you want to do a family assessment? My teenager is the patient, not the rest of us." Select the nurse's best response. a. "Family dysfunction might have caused the mental illness" b. "Family assessment is part of the protocol for care of all patients with mental illness" c. "Family members provide more accurate information than the patient" d. "Every family member's perception of events is different and adds to the total picture

d. "Every family member's perception of events is different and adds to the total picture

Ali is a 17-year-old patient diagnosed with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? a. "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." b. "I always purge when I'm alone so that I'm not a bad role model for my younger sister." c. "I purge only once a day now instead of twice." d. "I am a hard worker and I am very compassionate toward others."

d. "I am a hard worker and I am very compassionate toward others."

How does Harry Stack Sullivan's Interpersonal Theory view anxiety? a. A sign of guilt in adults. b. The result of trying to go beyond experiences of guilt and pain. c. An emotional experience felt after the age of 5 years. d. A painful emotion arising from social insecurity.

d. A painful emotion arising from social insecurity.

When working with a client who may have made a covert reference to suicide, the nurse should base the response on what statement? a. Being careful not to mention the idea of suicide. b. Listening carefully to see whether the client mentions suicide more overtly. c. Asking about the possibility of suicidal thoughts in a covert way. d. Asking the client directly if they are thinking of attempting suicide.

d. Asking the client directly if they are thinking of attempting suicide.

What is the primary function of the nurse generalist in caring for families? a. Determining the new skills the family needs b. Conducting private family therapy sessions c. Prescribing psychobiological intervention d. Assessing the amount of stress on the system

d. Assessing the amount of stress on the system

A 7-year-old, who is described as impulsive and hyperactive, tells the nurse, "I am a dummy, because I don't pay attention, and I can't read like the other kids." The nurse notes that these behaviors are most consistent with which diagnosis? a. Attention deficit disorder b. Conduct disorder c. Autism d. Attention deficit hyperactivity disorder

d. Attention deficit hyperactivity disorder

What is the premise underlying behavioral therapy? a. Motives must change before behavior changes. b. Behavior is determined by cognitions; change in cognitions produces new behavior. c. Behavior is a product of unconscious drives. d. Behavior is learned and can be modified.

d. Behavior is learned and can be modified.

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract. What intensity of nursing observation should be instituted? a. Every 15-minute observation around the clock b. Seclusion with 15-minute observation c. One-to-one observation while client is awake d. Constant 24-hour, one-to-one observation at arm's length

d. Constant 24-hour, one-to-one observation at arm's length

A client hospitalized for a psychotic relapse is being discharged home to family. Which topic is important to address when teaching both the client and the family to recognize possible signs of impending mania? a. Decreased social interaction b. Increased appetite c. Increased attention to bodily functions d. Decreased sleep

d. Decreased sleep

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

d. Denial

When a colleague committed suicide, the nurse stated, "I do not understand why she would take her own life." This is an expression of which feeling? a. Confusion b. Sympathy c. Anger d. Disbelief

d. Disbelief

A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." What is the best initial approach to managing this behavior? a. Enforcing consequences by responding, "Let's walk down to the seclusion room." b. Reprimand the client by stating, "What an offensive thing to suggest!" c. Clarifying the nurse-client relationship by stating, "I don't have sex with clients." d. Distracting the client by suggesting, "It's time to work on your art project."

d. Distracting the client by suggesting, "It's time to work on your art project."

Which nursing intervention is appropriate for the management of intermittent explosive disorder? a. Setting up loose boundaries so the client will feel relaxed b. Providing intensive family therapy c. Limiting decision-making opportunities to avoid frustration d. Establishing a trusting relationship with the client

d. Establishing a trusting relationship with the client

A family consists of a husband, a wife, their three children, and the wife's mother. This family form is referred to using which term? a. Blended b. Indwelling c. Dyadic d. Extended

d. Extended

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

d. Fear of gaining weight

Which side effects of lithium can be expected at therapeutic levels? a. Coarse hand tremor and gastrointestinal upset b. Nausea and thirst c. Ataxia and hypotension d. Fine hand tremor and polyuria

d. Fine hand tremor and polyuria

Which behavior is most indicative of a 4-year-old child diagnosed with Tourette's syndrome? a. Humming while performing activities that require concentration b. Difficulty in social relationships c. Difficulty in completing tasks on time d. Frequent eye blinking

d. Frequent eye blinking

A client hospitalized with anorexia nervosa has a weight that is 65% of normal. For this client, what is a realistic short-term goal for the first week of hospitalization regarding the physical impact of his/her weight? a. Verbalize awareness of the sensation of hunger. b. Develop a pattern of normal eating behavior. c. Discuss fears and feelings about gaining weight. d. Gain a maximum of 3 lb.

d. Gain a maximum of 3 lb.

The members of a family openly tell each other what they are thinking and feeling. A nurse listening to their interchanges would assess their communication using which term? a. Disengaged b. Double-bind c. Generalizing d. Healthy

d. Healthy

The nurse is caring for an adult client who experienced severe physical abuse from the age of 2 through 12. What information should the nurse provide the client concerning the function of the "id" and the ability to function as an adult? a. It provides an individual with the ability to differentiate believed and real experiences. b. It has control over the emotional frustration felt as an adult. c. It is severely damaged by abuse experienced before the age of 5 years. d. It is the source of one's survival instincts.

d. It is the source of one's survival instincts.

The nurse observes the meal tray about to serve a suicidal client. Which item should be removed from the tray? a. Plastic plate b. Cloth napkin c. Styrofoam cup d. Metal utensils

d. Metal utensils

Role-playing is associated with which type of psychotherapy? a. Systematic desensitization b. Operant conditioning c. Psychoanalysis d. Modeling

d. Modeling

The family that consists of a married mother and father and three biological children all living together is referred to using which term? a. Other family b. Cohabitating family c. Blended family d. Nuclear family

d. Nuclear family

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? a. They tend to be more effective for men. b. They often cause the client to have diurnal variation. c. Recent memory impairment is commonly observed. d. Onset of action is from 1 to 3 weeks or longer.

d. Onset of action is from 1 to 3 weeks or longer.

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

d. Patients with bulimia often appear at a normal weight.

A nuclear family consists of married parents, a 16-year-old daughter, and a 19-year-old son recently diagnosed with schizophrenia. The rest of the family is bewildered with his symptoms and express that they feel lost in knowing how to deal with things. Which of the following approaches to family therapy should the nurse implement at this time to provide support and give information to the family that will help them cope with their son's illness? a. Insight-oriented family therapy b. Multigenerational family therapy c. Behavioral family therapy d. Psychoeducational family therapy

d. Psychoeducational family therapy

When a client experiences four or more mood episodes in a 12-month period, which term is used to describe this behavior? a. Incongruent b. Cyclothymic c. Dyssynchronous d. Rapid cycling

d. Rapid cycling

Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa? a. Chronic low self-esteem b. Ineffective coping: impulsive responses to problems c. Disturbed body image d. Risk for injury: electrolyte imbalance

d. Risk for injury: electrolyte imbalance

During a family therapy session a wife states, "My husband is always angry. The children and I are always on edge. We can never relax." The nurse identifies the wife's communication technique using which term? a. Generalizing b. Placating c. Manipulating d. Distracting

a. Generalizing

3. Choose the most likely options to complete the statement below. Based on the client's condition, the priority need at this time will be for the nurse to first address the issue of ____1_____, followed by interventions to address ____2______ and _____3 ______.

1) Risk for violence and danger to self 2) Anxiety over hallucinations 3) Lack of impulse control

Darnell is a 20-year-old male being admitted to a state psychiatric hospital accompanied by his brother. His clothing is rumpled, and his overall hygiene is poor. He reports hearing voices. Darnell states, "I do not have time for this. I make and sell rare guitars. You've got to get out there and sell yourself, day and night, and that's what I do." The intake nurse notices that the patient talks rapidly and with few breaks. "I don't need sleep. I need investors, people who believe in art, real art, you know? But you have to watch your back. There are people who hate genius, and there are people who know what I've got and want to take it away from me. You have to fight for this." He eyes his brother angrily. Vital signs indicate a BP of 142/90 with a resting heart rate of 102, and a skin turgor time of 4 seconds. He scores an 8 on the Altman Self-Rating Mania Scale. The health care provider assigns an initial diagnosis of Bipolar I disorder, complicated by a history of ADHD and migraines. 1. Choose the most likely options to complete the following statement. This patient's symptoms are most indicative of a(n) ____1_____ episode because his symptoms include ____2______, and ___3______.

1. Manic 2. Delusions 3. Hallucinations

Which behavior would be characteristic of a client during a manic episode? a. Going rapidly from one activity to another b. Being unwilling to leave home to see other people c. Taking frequent rest periods and naps during the day d. Watching others intently and talking little

a. Going rapidly from one activity to another

A client tells the nurse that he believes his situation is intolerable and is observed isolating socially. Which nursing diagnosis should be considered? a. Hopelessness b. Compromised family coping c. Deficient knowledge d. Chronic low self-esteem

a. Hopelessness

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? a. It is high risk, or a hard method. b. Considering the results, it is a nonlethal means. c. It was not an actual suicide attempt because the client was intoxicated. d. It is low risk, or a soft method.

a. It is high risk, or a hard method.

A client diagnosed with bipolar disorder has a nursing care plan that includes several nursing diagnoses listed. Match the nursing diagnosis to the level of priority (1 to 4). a. Nonadherence b. Risk for injury c. Knowledge, deficient d. Self-care deficit, bathing, and hygiene

First priority----b. Risk for injury Second priority----d. Self-care deficit, bathing, and hygiene Third priority----c. Knowledge, deficient Fourth priority----a. Nonadherence

When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? a. It will be prescribed at a higher than typical dose. b. Long-term management of symptoms is best achieved with tricyclic antidepressants. c. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. d. It will reduce the need for cognitive therapy.

a. It will be prescribed at a higher than typical dose.

A 12-year-old male patient diagnosed with Tourette's disorder is visiting his healthcare provider. The nurse will prepare medication teaching on which class of medication to help manage the tics associated with this disorder? (Select all that apply.) a. First-generation antipsychotics b. Alpha 2-adrenergic agonists c. Second-generation antipsychotics d. Anticholinesterase inhibitors e. Mood stabilizers

a, b, c a. First-generation antipsychotics b. Alpha 2-adrenergic agonists c. Second-generation antipsychotics

An 8-year-old patient is newly diagnosed with attention deficit hyperactivity disorder (ADHD). It is important that the parents be educated to the fact that symptoms will take which form? (Select all that apply). a. Mood swings b. Poor school performance c. Impulsive behaviors d. Easily intimidated e. Low frustration tolerance

a, b, c, e a. Mood swings b. Poor school performance c. Impulsive behaviors e. Low frustration tolerance

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

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

Currently what is understood to be the causation of schizophrenia? a. A combination of inherited and nongenetic factors b. Deficient amounts of the neurotransmitter dopamine c. Excessive amounts of the neurotransmitter serotonin d. Stress related and ineffective stress management skills

a. A combination of inherited and nongenetic factors

Which family situation should the nurse assess as warranting a referral for family therapy? a. A couple is having difficulty dealing with the erratic behavior of their bipolar son. They say, "We're at the end of our rope." b. A couple is having their first child. They say, "It's certainly going to be a change for us." c. The parents of a blended family with five children ranging in age from 5 to 15 years say, "It's never quiet, but the disagreements eventually get worked out." d. A husband and wife are sending a son off to college and planning their daughter's wedding. They say, "Soon we will be back to having an empty nest again."

a. A couple is having difficulty dealing with the erratic behavior of their bipolar son. They say, "We're at the end of our rope."

Which situation is the best example of a double bind? a. A wife sighs while telling her husband, "You can go out with the boys tonight if it's what you really want to do." b. A man says, "I was surprised and delighted when my entry was chosen for an award." c. A mother tells her son, "Under no circumstances will I give you permission to stay out after midnight." d. A roommate states, "I would prefer to have you call if you think you are going to be late for dinner."

a. A wife sighs while telling her husband, "You can go out with the boys tonight if it's what you really want to do."

What is a desired outcome for the maintenance phase of treatment for a manic client? a. Adhere to follow-up medical appointments. b. Take medication more than 50% of the time. c. Use alcohol to moderate occasional mood "highs." d. Exhibit optimistic, energetic, playful behavior.

a. Adhere to follow-up medical appointments.

Which of the following would be assessed as a negative symptom of schizophrenia? a. Anhedonia b. Hostility c. Agitation d. Hallucinations

a. Anhedonia

A client, who has been prescribed clozapine 6 weeks ago, reports flulike symptoms including a fever and a very sore throat, the nurse should initiate which nursing intervention? a. Arrange for the client to have blood drawn for a white blood cell count. b. Advise the physician that the client should be admitted to the hospital. c. Suggest that the client take something for the fever and get extra rest. d. Consider recommending a change of antipsychotic medication.

a. Arrange for the client to have blood drawn for a white blood cell count.

Using Maslow's model of needs, the nurse providing care for an anxious client identifies which intervention as being a priority? a. Assessing the client for strengths upon which a nurse-client relationship can be based b. Assessing the client's ability to fulfill appropriate developmental level tasks c. Planning one-on-one time to assist in identifying the fears trigger the client's anxiety d. Evaluating the client's ability to learn and retain essential information regarding their current condition

a. Assessing the client for strengths upon which a nurse-client relationship can be based

2. The patient is not progressing as well as the treatment team has hoped. Identify the assessment findings that require immediate follow-up by the nurse. Select all that apply. a. Averaging 2 to 3 hours of sleep per night. b. Attention to hygiene is performed every 2 days. c. Prefers solitary to group activities. d. Eats finger foods while reading as opposed to dining with others in the dining area. e. Is calmer but not able to concentrate on all tasks at hand.

a. Averaging 2 to 3 hours of sleep per night.

The nurse is preparing to set goals for a 10-year-old diagnosed with an impulse control disorder. To best ensure the expected therapeutic outcomes, the nurse includes goals that focus on what client need? a. Client centered and includes the client's input b. Family centered and long term in nature c. Age appropriate and achievable in a short period of time d. Simple and easily defined

a. Client centered and includes the client's input

What term is used to identify the condition demonstrated by a person who has numerous hypomanic and dysthymic episodes over a two-year period? a. Cyclothymia. b. Bipolar II disorder. c. Bipolar I disorder. d. Seasonal affective disorder.

a. Cyclothymia.

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

a. Disruption of the fluid and electrolyte balance

What term best describes a family dynamic where boundaries are not clear and whose members are overinvolved with each other? a. Enmeshment b. Scapegoating c. Clear boundaries d. Rigid boundaries

a. Enmeshment

A client diagnosed with conduct disorder craves what experience? a. Excitement without concern for possible negative outcomes b. Control of situations and constantly strategizes for such power c. Friendship but from those older than themselves d. Material possessions but lacks focus and direction

a. Excitement without concern for possible negative outcomes

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. What information should the nurse provide the client regarding this practice? a. Explain the high possibility of an adverse reaction. b. Agreeing that this will help the client to remember the medications. c. Caution the client to drink several glasses of water daily. d. Suggest that the client also use a sun lamp daily.

a. Explain the high possibility of an adverse reaction.

2. Indicate which assessment finding is associated with each of the following symptom categories. Each item may fit more than one category. a. Mood swings from weeping to laughing to withdrawal b. Shows no interest in food, self-care, and socialization c. Appears to hear and respond to voices d. Clang association in speech patterns e. Knocks objects that irritate her off the table f. Difficulty putting on an item of clothing g. Exhibits anhedonia h. Lashes out in unexpected anger

a. Mood swings--pos, affect b. Shows no interest--neg c. Appears to hear--pos, d. Clang--pos e. Knocks objects--pos, cog, affect f. Difficulty putting on--pos, cog g. anhedonia--neg h. Lashes out--pos, affect

A client diagnosed with schizophrenia states to the nurse, "My, oh my. My mother is brother. Anytime now it can happen to my mother." What is the nurse's best response? a. "I will get you a prn medication for agitation." b. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?" c. "You are having problems with your speech. You need to try harder to be clear." d. "You are confused. I will take you to your room to rest a while."

b. "I'm sorry, I didn't understand that. Do you want to talk more about your mother as we did yesterday?"

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide> Select the 3 that apply: a. an adverse effect of this medication is CNS depression b. take the medication in the morning c. this medication blocks the synaptic reuptake of serotonin in the brain d. monitor for weight loss while taking this medication e. therapeutic effects of this medication will take 1-3 weeks to fully develop

b, c, d b. take the medication in the morning c. this medication blocks the synaptic reuptake of serotonin in the brain d. monitor for weight loss while taking this medication

The family of a child diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type, is told the evaluation of their child's care will focus on symptom patterns and severity. What is the focus of child's evaluation? (Select all that apply.) a. Physical growth b. Activities of daily living c. Personal perception d. Academic performance e. Social relationships

b, c, d, e b. Activities of daily living c. Personal perception d. Academic performance e. Social relationships

2. Once Sophia is medically stable, which action will the nurse plan to implement? Select all that apply. a. Initiate recovery with US Food and Drug Administration (FDA) approved medications for anorexia nervosa. b. Educate the patient regarding integrative approaches that may be used, along with the need to contact healthcare providers before using herbal therapy. c. Use the patient's fatigue to engage cooperation in the treatment plan. d. Ensure that the patient consumes vegetables and other high-fiber foods within the first 3 days to relieve constipation. e. Prioritize family-based treatment (F-BT) over individual therapies. f. Seek to understand the patient's culture and personal belief system.

b, c, e, f b. Educate c. Use the patient's fatigue e. Prioritize family-based f. Seek to understand t

Nurses should assess the lethality of the client's plan for suicide. What factor would be irrelevant to that assessment? (Select all that apply.) a. How long the client has been suicidal b. Whether the plan has specific details c. Has the client been suicidal in the past d. Whether the method is one that could cause death e. Whether the client has the means to implement the plan

b, d, e b. Whether the plan has specific details d. Whether the method is one that could cause death e. Whether the client has the means to implement the plan

Shannon, 47 years old, is brought to the emergency department after striking her case manager at a homeless shelter. Due to the potential for danger to others and a need for care, she is admitted to the psychiatric unit. Prior documentation identifies a history of schizophrenia, which has not been consistently treated since she became homeless.On the unit Shannon shows no interest in—and resists—all food, self-care, and social activities. She wears a sweater upside down. Her mood is labile, ranging from tearfulness, laughter, and withdrawal. She stands by the window, studying the sky "for signs," saying that messages appear in cloud formations. When a staff member asks her about the messages, she shouts, "Stay out of my head!" and pushes him away. On her way to lunch she knocks objects off the table that irritate her—a puzzle box, a small stack of magazines, and a container of buttons, all the while saying "Clutter clutter, flutter flutter." 1. This patient is most likely experiencing which types of delusion? Select all that apply: a. Persecutory b. Referential c. Somatic d. Erotomanic e. Control f. Nihilistic

b, e b. Referential e. Control

The nurse providing anticipatory operant conditioning guidance to the mother of a toddler should advise that childhood temper tantrums are best handled by which intervention? a. Scolding the child when he/she displays tantrum behaviors b. Ignoring the tantrum and giving attention when the child acts appropriately c. Giving the child what he/she is asking for d. Spanking the child at the onset of the tantrum behaviors

b. Ignoring the tantrum and giving attention when the child acts appropriately

Which nursing intervention is designed to help a schizophrenic client minimize the occurrence of a relapse? a. Schedule the client to attend group therapy that includes those who have relapsed. b. Schedule the client to attend group therapy that includes those who have relapsed. c. Schedule the client to attend group therapy that includes those who have relapsed. d. Help the client and family adapt to the stigma of chronic mental illness and periodic relapses.

b. Schedule the client to attend group therapy that includes those who have relapsed.

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? a. "I will not take any over-the-counter medication while on the fluoxetine." b. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." c. "I will report increased thirst and urination to my provider." d. "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction."

b. "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away."

Which statement would best show acceptance of a depressed, mute client? a. "It is important for you to share your thoughts with someone who can help you evaluate your thinking." b. "I would like to sit with you for 15 minutes now and again this afternoon." c. "Each day we will spend time together to talk about things that are bothering you." d. "I will be spending time with you each day to try to improve your mood."

b. "I would like to sit with you for 15 minutes now and again this afternoon."

A nurse expresses an exclusive belief in the biological model for mental illness when stating "it's the only one I really believe." What conclusion should be drawn from this statement? a. The biological model has been proven to be successful in finding the cause of most symptoms of mental illness. b. In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account. c. The biological model is the most popular theory among leading psychiatrists and therefore the one that should be fully embraced. d. The biological model is the oldest and most reliable model for explaining mental illness

b. In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account.

A girl is overheard saying to her brother, "If you stick up for me with mom and dad, I will forget I heard you planning to sneak out after they are asleep." This can be assessed as what type of communication? a. Placating b. Manipulative c. Generalizing d. Scapegoating

b. Manipulative

During family therapy the family's youngest daughter says, "They care more about my sister because she's older and gets straight As in school." Which nursing diagnosis should be given priority? a. Parental role conflict b. Relational problems c. Deficient knowledge d. Defensive coping

b. Relational problems

Which nursing intervention demonstrates the theory behind operant conditioning? a. Showing the client how to be assertive without being aggressive b. Rewarding the client with a token for avoiding an argument with another client c. Explaining to the client the consequences of not following unit rules d. Demonstrating deep breathing techniques to a group of clients

b. Rewarding the client with a token for avoiding an argument with another client

What is the priority nursing diagnosis for a hyperactive manic client during the acute phase of treatment? a. Impaired verbal communication b. Risk for injury/suicide c. Ineffective role performance d. Risk for other-directed violence

b. Risk for injury/suicide

Biological theorists suggest that the cause of eating disorders may be related to which factor? a. Body image disturbance b. Serotonin imbalance c. Dopamine excess d. Normal weight phobia

b. Serotonin imbalance

What is the major reason for the hospitalization of a depressed client? a. Inability to go to work b. Suicidal ideation c. Psychomotor agitation d. Loss of appetite

b. Suicidal ideation

Which side effect of antipsychotic medication is generally nonreversible? a. Pseudoparkinsonism b. Tardive dyskinesia c. Dystonic reaction d. Anticholinergic effects

b. Tardive dyskinesia

The family consists of the husband and his wife, their four children, the wife's 21-year-old sister, and client's elderly aunt. Which members are considered the client's nuclear family? a. The husband and his aunt b. The parents and their four children c. The wife and her sister d. The four children and the wife's sister

b. The parents and their four children

What are the most important characteristics for staff members who work with suicidal clients? a. Problem-solving skills b. Warm, consistent interaction c. Effective interview and counseling skills d. Organization

b. Warm, consistent interaction

After stabilization of symptoms, what is the primary focus of treatment for a client diagnosed with anorexia nervosa? a. Improving interpersonal skills b. Weight restoration c. Learning effective coping methods d. Changing family interaction patterns

b. Weight restoration

Parents of a teenager recently diagnosed with serious mental illness express dismay. One parent says, "Our hopes for our child's future are ruined. We probably won't ever have grandchildren." The nurse will use interventions to assist with what? a. denial b. acceptance c. manipulation d. acting out

b. acceptance

A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? a. add extra calories to the diet as between-meal snack b. eat a diet high in fiber c. check temperatures daily d. take medication first thing in the morning before eating

b. eat a diet high in fiber

A 15-year-old is hospitalized after a suicide attempt. This adolescent lives with the mother, stepfather, and several siblings. When performing a family assessment, what must the nurse first determine? a. the meaning that the patient's suicide attempt has for family members b. names and relationships of the family's members c. the communication patterns between the patient and parents d. how the family expresses and manages emotion

b. names and relationships of the family's members

A teenaged client is being discharged from the psychiatric unit with a prescription for risperidone. The nurse providing medication teaching to the client's mother should provide which response when asked about the risk her child faces for extrapyramidal side effects (EPSs)? a. All antipsychotic medications have an equal chance of producing EPSs. b. Advise the mother to ask the provider to change the medication to clozapine instead of risperidone. c. Newer antipsychotic medications have a higher risk for EPSs. d. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics.

d. Risperidone is a newer antipsychotic medication and has a lower risk of EPSs than older antipsychotics.

What assessment tool is useful to nurses in rating suicide risk? a. AIMS scale. b. Mini-Mental Status Examination. c. CAGE questionnaire. d. SAFE-T.

d. SAFE-T.

When a nurse assesses the style of behavior a child habitually uses to cope with the demands and expectations of the environment, he or she is assessing characteristic? a. Cultural assimilation b. Resilience c. Vulnerability d. Temperament

d. Temperament

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! All you ever do is ask me the same question over and over. Get out of here!" What fact concerning hostility should the nurse's response be based upon? a. The client is probably experiencing transference. b. The client may be angry at someone else and projecting that anger to staff. c. The client is getting better and is able to be assertive. d. The client may be at high risk for self-harm.

d. The client may be at high risk for self-harm.

When the partner of a manic client asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on which information? a. Much depends on the socioeconomic class of the individuals. b. Highly creative people tend toward development of the disorder. c. No research exists to suggest genetic transmission. d. The rate of bipolar disorder is higher in relatives of people with bipolar disorder.

d. The rate of bipolar disorder is higher in relatives of people with bipolar disorder.

A 10-year-old who is frequently disruptive in the classroom begins to fidget in her chair and then moves on to disruptive behavior. What is the most appropriate initial technique for managing this sort of disruptive behavior? a. Therapeutic holding b. Quiet room c. Seclusion d. Touch control

d. Touch control

A nurse works with a nuclear family that includes an adult child diagnosed with schizophrenia. The child's mother confides that she and her husband "have not been getting along well." She states that her teenage daughter provides much support to her and claims that "she doesn't really like her dad much anymore and doesn't talk to him." The nurse suspects that the family is experiencing which family dysfunctional dynamic? a. Boundary blurring b. Neglect c. Emotional abuse d. Triangulation

d. Triangulation

When parents share that their 8-year-old child seems to "always try to be annoying and hateful," the nurse suspects the child is demonstrating which characteristic? a. Depression b. Emotionally immature c. Anxiety d. Vindictiveness

d. Vindictiveness

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? a. Prompting the client if the reply is slow b. Reviewing the client's medical record to support the client's response c. Repeating the question if the client does not answer promptly d. Waiting quietly for the client to reply

d. Waiting quietly for the client to reply

When a client reports that lithium causes an upset stomach, the nurse should make which suggestion associated with taking the medication? a. 2 hours after meals b. With an antacid c. 30 minutes before meals d. With meals

d. With meals

What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? a. Advise the client to curtail salt intake for 24 hours. b. Continue to administer medication as ordered. c. Advise the client to limit fluids for 12 hours. d. Withhold medication and notify the physician.

d. Withhold medication and notify the physician.

Assessment data for a 7-year-old reveals an inability to take turns, blurting our answers to questions before a question is complete, and frequently interrupting others' conversations. How should the nurse document these behaviors? a. disobedience b. hyperactivity c. anxiety d. impulsivity

d. impulsivity

Parents of a mentally ill teenager say, "We have never known anyone with was mentally ill. We have no one to talk to because none of our friends understand the problems we are facing." Select the nurse's most helpful intervention. a. facilitate achievement of normal developmental tasks of the family b. build the parents' self-concept as coping parents c. teach the parents techniques of therapeutic communication d. refer the parents to a support group

d. refer the parents to a support group

Which nursing diagnosis should be considered for a child with attention deficit hyperactivity disorder ADHD? a. defensive coping b. impaired verbal communication c. Anxiety d. risk for injury

d. risk for injury

When a hyperactive manic client expresses the intent to strike another client, what is the initial nursing intervention? a. question the client's motive. b. initiate physical confrontation. c. prepare the client for seclusion. d. set verbal limits.

d. set verbal limits.

The purpose of the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has been diagnosed with schizophrenia is early detection of a. cholestatic jaundice. b. acute dystonia. c. pseudoparkinsonism. d. tardive dyskinesia.

d. tardive dyskinesia.

A poorly developed sense of empathy is thought to be the result of having what life experience? a. A family history of mental illness b. suffered head trauma at an early age c. a low serum testosterone level d. unmet physical and emotional needs

d. unmet physical and emotional needs

1. Identify the nursing actions as 1—indicated (appropriate or necessary), 2—contraindicated (could be harmful), or 3—nonessential (not necessary) for the patient's care at this time. Only one selection can be made for each nursing action. a. Establish a therapeutic nurse/patient relationship that respects personal boundaries b. Begin refeeding in a structured environment, including precise time and duration of meals c. Minimize the social nature of eating; focus conversation on the texture and tastes of the food d. As the patient approaches the goal weight, encourage her to prepare a meal for a loved one e. Weigh patient three times daily after each meal, in underwear only, for the first week f. Set a goal for the patient to achieve a 5-pound weight gain in 1 week g. Regard evaluation as taking place over time rather than as a fixed event

indicated: a-establish relationship, b-begin refeeding, g-regard evaluation contraindicated: c-minimize the social nature, e-weigh patient, f-set a goal 5 pounds nonessential: d-prepare meal for loved one

4. The nurse creates an initial nursing care plan for this client. Identify the nursing actions as Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-essential (not necessary) for the patient's care at this time. Only one selection can be made for each nursing action. a. Encourage the client to write letters to family members. b. Encourage exercise. c. Encourage rest. d. Ensure that the client sits down for three full, nutritious meals a day in the dining area. e. Encourage socialization and involvement in group activities. f. Provide carefully detailed explanations of all rules and expectations. g. Provide flexibility until the client gets used to the rules. h. Provide foods like milk shakes or sandwiches on demand.

indicated: b. Encourage exercise. c. Encourage rest. h. Provide foods like milk shakes contraindicated: d. Ensure that the client sits down, e. Encourage socialization , f. Provide carefully, g. Provide flexibility nonessential: a. Encourage the client to write