Psych Quiz #6 Varcarolis: 18, 19, 27, 29, 30
It has been 6 months since a woman was raped. Which statement by the client would indicate that counseling has helped her to achieve an important long-term outcome? "I'm not having as many nightmares about the rape so I do get a little sleep at night." "My husband has been very supportive during this whole thing." "I am not going to let that rapist be in control of my life. I know things will keep getting better." "I am not pressing charges because I want this whole thing to be over with so I can move on."
"I am not going to let that rapist be in control of my life. I know things will keep getting better." The correct option expresses empowerment and hope for the future. Long-term outcome includes the absence of any residual symptoms after the trauma and would be indicated by healing of physical injuries, relief of anger in nondestructive ways, comfort in relationships, and feelings of empowerment and expression of hope. While there has been an improvement, having nightmares and not sleeping well indicates that the patient is still going through acute stress related to the rape. The fact that the husband is supportive is a positive statement regarding her husband but doesn't express her own indicators of recovery. Not pressing charges may indicate that the patient may not be dealing with the event in a healthy way by avoiding the trauma.DIF: Cognitive Level: Analyze (Analysis)REF: page 16TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity
Which statement by a patient who was educated about the importance of acquiring adequate sleep indicates a need for further teaching? "I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." "Getting less than 6 hours of sleep at night may increase my risk for medical problems." "Getting enough sleep will increase my productivity at work." "Since I have to drive for my job, getting enough sleep will help me avoid accidents."
"I will be sure to try to get 8 hours of sleep every night, and 9 or 10 hours of sleep if I can." Sleeping more than 8 hours per night is associated with up to a twofold increased risk of obesity, diabetes, hypertension, incident cardiovascular disease, stroke, depression, and substance abuse. The other options are all true.DIF: Cognitive Level: Analyze (Analysis)REF: page 4TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity
You are working on an adolescent psychiatric unit. A 16 year old being treated on an adolescent psychiatric unit has become angry and is in the hallway yelling, "It's not fair! You all hate me! I hate this place!" When the client begins pounding his/her fists on the wall the nurse should attempt to de-escalate the situation by providing which response? "I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" "You may yell and bang your fists but you must do it in your own room so you don't upset the other patients." "Stop that right now! I will not allow you to behave like that!" "You will have to go into seclusion and restraints right now in order to be safe."
"I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" Approaching the patient in a calm manner and giving choices may de-escalate the situation and gives the patient some control. The patient would not be allowed to yell or possibly hurt himself/herself if left alone in his/her room. Commands such as "stop that right now!" could further escalate the situation. Seclusion and restraint may be premature because the situation may be able to be resolved using least restrictive means.DIF: Cognitive Level: Analyze (Analysis)REF: page 15TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment
One criterion for the diagnosis of primary insomnia is met when the client makes which statement? "I've actually missed work because I'm too tired to go." "I was diagnosed with depression 2 months ago." "I've had problems falling asleep for 3 weeks now." "I have these terrible nightmares when I fall asleep."
"I've actually missed work because I'm too tired to go." A criterion for primary insomnia listed in the DSM-5 is disruption of the normal routine as a result of the sleep disturbance. None of the other options relate to the stated criteria.REF: 360, DSM-5 Box Insomnia Disorder
Which of the following statements by a woman who was sexually assaulted a year ago would indicate that she has recovered from the trauma? "I don't walk home alone anymore because I am terrified it may happen again." "I am sleeping better but still only get about 5 hours of sleep at night because of bad dreams about the rape." "I realize that I was partly to blame for the rape because of walking in an unsafe neighborhood." "My husband and I are having sex again and I enjoy it."
"My husband and I are having sex again and I enjoy it." Sexual assault survivors are considered to be recovered if they are relatively free of any signs or symptoms of acute stress disorder and posttraumatic stress disorder. Signs of recovery include sleeping well with few instances of nightmares or dreams, being only mildly fearful, having positive self-regard, and returning to prerape sexual functioning and interest. The closer the survivor's lifestyle is to how it was before the rape, the more complete the recovery has been. Not walking home because of being terrified indicates a high level of fear. Only sleeping 5 hours at night indicates sleeping is still seriously disturbed. Stating that she is partly to blame indicates that the patient is placing the blame for the rape on herself instead of the perpetrator.DIF: Cognitive Level: Analyze (Analysis)REF: page 23TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity
A client diagnosed with a chronic sleep disorders begins to cry and states, "I can't keep going like this! I work in a bank and if I can't function correctly I'll lose my job. I just don't think I'll get better." Which statement provides a therapeutic response to the client's concerns? "Don't worry! I'm sure with treatment everything will get better." "You are not alone. Many people who come for sleep studies are going through the same thing." "You seem so sad. May I ask if something else is troubling you?" "There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work."
"There is much hope for improvement through treatment. Let's talk about some strategies for your problems at work." This response instills hope regarding the ability of the patient to improve and suggests positive strategies for daily functioning. The other responses are nontherapeutic.DIF: Cognitive Level: Apply (Application)REF: page 25TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
Which assessment question best demonstrates the nurse's understanding of a dying client's needs? "What are your hopes for your final days?" "Have you completed a Living Will?" "Are you aware of the pain control options available?" "Do you have any concerns about paying for your end-of-life care?"
"What are your hopes for your final days?" Care of the dying is a nursing responsibility. The focus of this care needs to shift toward the question, "What do you hope for at the end of your life?" rather than managing the cost of medical care. Pain management and advance directives are only individual aspects of end of life care.DIF: Cognitive Level: Analyze (Analysis)REF: page 4TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity
The nurse in an emergency department notices a patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which statement should the nurse make to the spouse to help prevent escalation and/or violence? "You need to stay with your wife. She needs you." "Hey, what's up? You look out of control." "I am calling security to deal with your behavior." "You appear upset. Can I help you with anything?"
"You appear upset. Can I help you with anything?" Approaching a patient or a visitor with a calm, sincere, and caring manner can de-escalate a situation because the person may feel you are interested in helping. The other responses will not prevent escalation and may in fact anger the person further.DIF: Cognitive Level: Analyze (Analysis)REF: page 14TOP: Nursing Process: ImplementationMSC: NCLEX: Safe and Effective Care Environment
A client reports symptomatology that supports the diagnosis of sleep paralysis. The nurse effectively assesses the client by asking which question? "Do you ever have nightmares?" "Have you ever fallen asleep while driving?" "Do you have a history of obsessive compulsive behavior?" "Is it difficult for you to fall asleep?"
"Have you ever fallen asleep while driving?" Clients with sleep paralysis can often also exhibit symptoms of narcolepsy such as extreme sleepiness resulting in falling asleep at inappropriate times. None of the other questions are directed toward this disorder.REF: 361-362
The nurse appropriately assesses an obese, hypertensive, Type 2 diabetic client when asking: "Do you regularly have nightmares?" "Is getting to sleep a problem for you?" "Do you snooze when you sleep?" "How much sleep do you usually get each night?"
"How much sleep do you usually get each night?" Short sleep duration has been associated with obesity, cardiovascular disease, hypertension, and diabetes. Neither nightmares nor snoring are as directly associated with short sleep duration. The remaining option is a general assessment question.REF: 364
What is the usual time period that medications to treat insomnia are usually prescribed? 1 to 2 days 1 to 2 months 3 weeks 2 weeks
2 weeks Nurses frequently provide education about the benefits of a particular sleep medication, the side effects, untoward effects, and the fact that medications are usually prescribed for no longer than 2 weeks because tolerance and withdrawal may result.REF: 367
Which subjective symptom should the nurse would expect to note during assessment of a client diagnosed with anorexia nervosa? Lanugo Hypotension 25-lb weight loss Fear of gaining weight
Fear of gaining weight Fear of weight gain is the only subjective data listed, and it is universally true of clients diagnosed with anorexia nervosa.REF: 334
Which neurotransmitter imbalance has been shown to be related to impulsive aggression? Low levels of ã-aminobutyric acid Low levels of serotonin High levels of norepinephrine High levels of acetylcholine
Low levels of serotonin Low serotonin levels have been implicated in several research studies as being a factor in impulsive aggression. Research does not support any of the other options.REF: 506
The client experiencing bulimia differs from the client diagnosed with anorexia nervosa by exhibiting which characteristic? Maintaining a normal weight Holding a distorted body image Doing more rigorous exercising Purging to keep weight down
Maintaining a normal weight Many bulimics are at or near normal weight, whereas clients with anorexia nervosa are underweight. The other characteristics are commonly shared among persons with either disorder.REF: 352
A client tells the nurse, "I just don't sleep more than 5 hours at night." The nurse assesses the client best for individual sleep requirements by asking which question? "Are you aware that some people require less sleep than others?" "When did this pattern of sleep start for you?" "Do you usually feel rested and alert when you get up?" "Are you taking any medication that could affect your sleep?"
"Do you usually feel rested and alert when you get up?" The most accurate way to determine an individual's sleep requirements is to ask if the person feels fully awake and functions effectively on the sleep he or she is getting. None of the other options address the issue from the client's perspective.REF: 366
Which statements identify a client's progress through the stages of grief? Select all that apply. "He didn't die; I'm sure he will be found and be just fine." "I will never accept he's gone; I will never give up looking for him." "If they find him, I'll never doubt miracles again." "I'll never understand why he risked his life by hitchhiking at night." "Knowing he's gone makes me so sad."
"He didn't die; I'm sure he will be found and be just fine." "If they find him, I'll never doubt miracles again." "I'll never understand why he risked his life by hitchhiking at night." "Knowing he's gone makes me so sad." The five stages of grief identified by Kübler-Ross include denial, anger, bargaining, depression, and acceptance. The statement concerning never giving up demonstrates the inability to accept the individual's death.DIF: Cognitive Level: Analyze (Analysis)REF: page 3TOP: Nursing Process: EvaluationMSC: NCLEX: Psychosocial Integrity
Ali is a 17-year-old patient with bulimia coming to the outpatient mental health clinic for counseling. Which of the following statements by Ali indicates that an appropriate outcome for treatment has been met? "I purge only once a day now instead of twice." "I feel a lot calmer lately, just like when I used to eat four or five cheeseburgers." "I am a hard worker and I am very compassionate toward others." "I always purge when I'm alone so that I'm not a bad role model for my younger sister."
"I am a hard worker and I am very compassionate toward others." An appropriate overall goal for the bulimic patient would include that the patient be able to identify personal strengths, leading to improved self-esteem. Purging only once a day instead of two is incorrect because the goal is to refrain from purging altogether. A goal is for the patient to express feelings without food references. Purging when alone is incorrect because the patient is still purging.DIF: Cognitive Level: Analyze (Analysis)REF: page 25TOP: Nursing Process: Outcome IdentificationMSC: NCLEX: Psychosocial Integrity
Which statement best illustrates support in giving care to a patient who has just been sexually assaulted? "I'm so sorry for what you have been through." "Don't worry. It's hard now, but everything will be alright." "I am going to stay with you. We can talk as long as you want to." "Let's talk about new coping skills you can use."
"I am going to stay with you. We can talk as long as you want to." The most effective approach for counseling in the emergency department or crisis center is to provide nonjudgmental care and optimal emotional support. Sympathy is not a therapeutic response and does not focus on the patient. Telling the patient not to worry is false reassurance. It is too soon to try to learn new coping skills because the patient is in an acute stress phase.DIF: Cognitive Level: Analyze (Analysis)REF: page 13TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity
How is anger best defined? An unhealthy way of releasing anxiety Doing intentional harm to others An expression of conflict with others A normal response to a perceived threat
A normal response to a perceived threat Anger is an emotional response to frustration of desires, a threat to one's needs (emotional or physical), or a challenge. It is a normal emotion that can even be positive when it is expressed in a healthy way. All the other options describe anger as being abnormal and/or dysfunctional.REF: 505
Which assessment finding is the best predictor of violence in a newly admitted client? A recent assault on a drinking companion A family history of bipolar disorder The nurse's subjective feeling that the client is uncooperative A childhood history of being bullied at school
A recent assault on a drinking companion The best predictor of violence is past episodes of violent behavior. None of the remaining options have the predictability of a previous demonstration of anger.REF: 508, Assessment Guidelines
What is the most effective nursing intervention regarding the accurate assessment of sleep disorders? A sleep diary Information regarding sleep cycles Client description of the symptomatology Assessment for substance abuse
A sleep diary Self-reported sleep patterns may be biased, and so clinical tools such as a sleep diary are helpful in accurately estimating total sleep time.REF: Page 365
Which event is most likely to contribute to a client's escalating anger? Watching violence on television Another client's depressed mood A staff member challenging them A staff member asking them to help another client
A staff member challenging them Punitive, threatening, accusatory, or challenging statements to the client should be avoided since they are likely to escalate the client's anger. None of the other options is as likely to escalate existing angry behavior.REF: 514
A client newly diagnosed with hypersomnolence asks about what medication will be prescribed to manage this disorder. The nurse will base his/her response based on what knowledge? There is no effective medication treatment for hypersomnolence disorder. Medication therapy with benzodiazepines may be initiated. A stimulant will most likely be prescribed. The client will be started on an anticholinesterase inhibitor.
A stimulant will most likely be prescribed. Pharmacotherapy with long-acting amphetamine-based stimulants such as methylphenidate and non-amphetamine-based stimulants such as modafinil are helpful in hypersomnolence disorder. The other options are incorrect because there is effective medication treatment; benzodiazepines are sedating and addictive; and anticholinesterase inhibitors are used for the treatment of dementia.DIF: Cognitive Level: Apply (Application)REF: page 12TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity
A 28-year-old married client who is seeking treatment after being raped tearfully asks the nurse, "What if I am pregnant?" The nurse's response should be guided by what knowledge? The risk of pregnancy after rape is high, up to 50%. About 5% of women who are raped become pregnant as a result. Reproductive functions shut down during a violent attack, and as a result pregnancy does not occur. The client may be worried about how her spouse will accept the baby.
About 5% of women who are raped become pregnant as a result. About 5% of women who are raped become pregnant as a result (Rape, Abuse & Incest National Network, 2008). Pregnancy prophylaxis can be offered in the emergency department after the results of the pregnancy test are available. The risk of pregnancy is not high after rape. Reproductive functions do not shut down during a violent attack. The patient may be worried about her spouse's reaction; however at this time most important consideration is to give the patient pertinent education regarding rape and pregnancy.DIF: Cognitive Level: Apply (Application)REF: page 14TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
Which form of grief involves concerns for the future? Disenfranchised Dysfunctional Anticipatory Maladaptive
Anticipatory Anticipatory grief or anticipatory mourning is when a future loss is being mourned in advance. None of the other options are associated with premature mourning for a loss that is likely to occur in the future.REF: 558
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? Mood stabilizers Antidepressants Anxiolytics Atypical antipsychotics
Antidepressants The antidepressant fluoxetine (Prozac, an SSRI) has proven useful in reducing obsessive-compulsive behavior after the patient has reached a maintenance weight. Anxiolytics would be prescribed for anxiety. Atypical antipsychotic agents may be helpful in improving mood and decreasing obsessional behaviors and resistance to weight gain. Mood stabilizers are not specifically used in treatment of eating disorders.DIF: Cognitive Level: Apply (Application)REF: page 16TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity
A client who has recently received a terminal cancer diagnosis has expressed the desire to, "stay out of the hospital and die at home." Which nursing intervention will best help the client achieve this end-of-life goal? Involving the client and his/her family in treatment decisions Encouraging adherence to the medical treatment plan Discussing available pain control measures Assistance with advance care planning
Assistance with advance care planning Advance care planning has helped patients and their families achieve end-of-life goals, avoid hospitalization, and increase hospice and palliative care use. While the other options are appropriate interventions, none are as focused on assuring the client's end-of-life goals that are documented supporting their achievement.DIF: Cognitive Level: Analyze (Analysis)REF: page 7TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
The death of which terminal ill client, who self-administered a lethal dose of medication, resulted in the state of California adopting a Right to Die law? Terri Schiavo Jack Kevorkian Karen Anne Quinlan Brittany Maynard
Brittany Maynard Brittany Maynard was diagnosed with inoperable brain cancer in January of 2014. She and her husband moved from their home state of California to Oregon so that she could participate in Oregon's Death with Dignity Act. On November 1, 2014, Brittany self-administered a lethal dose of medication obtained under Oregon law. After Brittany's death, California Governor Jerry Brown signed a right to die bill into law. While all the other options identify individuals that played a role in the campaign to legalize physician-assisted suicide, none of their deaths resulted in California's adoption of a right to die law.REF: 566
Which coping mechanism is used excessively by clients diagnosed with bulimia nervosa to cope with their obsession with their body image? Denial Humor Altruism Projection
Denial Denial of incongruence between body reality, body ideal, and body presentation is the mainstay of the client diagnosed with bulimia nervosa. None of the other mechanisms are as vital to their coping technique.REF: 344
A client diagnosed with bulimia nervosa uses enemas and laxatives to purge to maintain weight. What is the likely physiological outcome of this practice? Increase in the red blood cell count Disruption of the fluid and electrolyte balance Elevated serum potassium level Elevated serum sodium level
Disruption of the fluid and electrolyte balance Disruption of the fluid and electrolyte balance is usually the result of excessive use of enemas and laxatives. There would be a decrease in potassium and sodium levels while the concentration of but not actual red cell count would be affected.REF: 344
According to current theory, which statement regarding eating disorders is accurate? Eating disorders are psychotic disorders in which patients experience body dysmorphic disorder. Eating disorders are frequently misdiagnosed. Eating disorders are possibly influenced by sociocultural factors. Eating disorders are rarely comorbid with other mental health disorders.
Eating disorders are possibly influenced by sociocultural factors. The Western cultural ideal that equates feminine beauty with tall, thin models has received much attention in the media as a cause of eating disorders. Studies have shown that culture influences the development of self-concept and satisfaction with body size. Eating disorders are not psychotic disorders. There is no evidence that eating disorders are frequently misdiagnosed. Comorbidity for patients with eating disorders is more likely than not. Personality disorders, affective disorders, and anxiety frequently occur with eating disorders.DIF: Cognitive Level: Understand (Comprehension)REF: page 53TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity
What is the basic principle that is associated with hospice care? Family centered care Focus is on care not cure Treating client suffering Promoting client autonomy
Focus is on care not cure Hospice is a multidisciplinary team approach that focuses on patient care, not cures. Palliative care is patient and family-centered care that optimizes quality of life anticipating, preventing, and treating suffering. Palliative care addresses physical, intellectual, emotional, social, and spiritual needs. Palliative caregivers promote patient autonomy, access to information, and choice. Hospice care incorporates many of the principles of palliative care.DIF: Cognitive Level: Apply (Application)REF: page 5TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity
A depressed client is likely to report a sleep disorder that includes which characteristics? Frequent awakenings during the night Nightmares Difficulty falling asleep Sleepwalking
Frequent awakenings during the night Depressed clients often report normal sleep onset, followed by repeated awakenings during the second half of the night. While the other options may occur, they are not the most frequent characteristic.REF: 360-361
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? Gain a maximum of 3 lb. Develop a pattern of normal eating behavior. Discuss fears and feelings about gaining weight. Verbalize awareness of the sensation of hunger.
Gain a maximum of 3 lb. The critical outcome during hospitalization for anorexia nervosa is weight gain. A maximum of 3 pounds weekly is considered sufficient initially. Too-rapid weight gain can cause pulmonary edema. While all the remaining goals are appropriate, none have the physical focus that is the initial priority.REF: 340-341
When providing possible interventions to promote the safety of a client reporting symptoms of somnambulism, the nurse should include which intervention? Gating the stairways Sleeping on a mattress placed on the floor Regular bedtime dose of a benzodiazepine Avoiding the use of serotonergic medications
Gating the stairways Somnambulism or sleep walking can result in falls; gating the stairways may minimize that risk. None of the other options are associated with the dangers presented by sleepwalking.REF: 362
Which characteristic places the client at highest risk for violence directed at others? Has a history of recurrent severe depression Is in an alcohol rehabilitation program Has delusions of persecution Is experiencing somatic symptoms for which no organic basis is found
Has delusions of persecution The client who perceives others to be against him/her may lash out if he/she feels threatened. Depression and somatic symptoms are risk factors for self-directed violence.REF: 508
The nurse can determine that inpatient treatment for a client diagnosed with an eating disorder would be warranted when which assessment data is observed? Weighs 10% below ideal body weight. Has serum potassium level of 3 mEq/L or greater. Has a heart rate less than 60 beats/min. Has systolic blood pressure less than 70 mm Hg.
Has systolic blood pressure less than 70 mm Hg. Systolic blood pressure of less than 70 mm Hg is one of the established criteria signaling the need for hospitalization of a client with anorexia nervosa. It suggests severe cardiovascular compromise. None of the remaining options represent data aligned with the criteria for hospitalization.REF: 346-347
When approaching a client who is acting out aggressively, what interventions should the nurse implement to assure personal safety? Stand close to the client for reassurance and to convey caring. Have other staff as backup, and stay out of the client's personal space. Take the client to his/her room so that his/her privacy will be protected. Call security and wait until they arrive before approaching the client.
Have other staff as backup, and stay out of the client's personal space. Safety considerations for staff include enlisting other staff to be present, keeping a safe distance from the patient, and approaching the patient in a nonthreatening or nonconfrontational manner. None of the other options focus appropriately on staff safety; security personnel may escalate the patient's behavior and should be kept in the background until needed to assist. Furthermore, being alone in the client's room is not a safe environment when aggressive behavior is being demonstrated.DIF: Cognitive Level: Apply (Application)REF: page 15TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment
A 38-year-old patient referred for sleep studies reports frequent daytime lethargy, unintended lapses into sleep, and never feeling rested on awakening in the morning. These symptoms support which sleep-related diagnosis? Circadian rhythm disorder Hypersomnolence REM sleep behavior disorder Breathing-related sleep disorder
Hypersomnolence The patient with hypersomnolence reports recurrent periods of sleep or unintended lapses into sleep, frequent napping, nonrefreshing nonrestorative sleep regardless of the amount of time slept, and difficulty with full alertness during the wake period. Circadian rhythm sleep disorders occur when there is a misalignment between the timing of the individual's normal circadian rhythm and external factors that affect the timing or duration of sleep. Patients with REM sleep disorder display elaborate motor activity associated with dream mentation. Breathing-related sleep disorder is characterized by frequent upper airway obstruction.DIF: Cognitive Level: Apply (Application)REF: page 13TOP: Nursing Process: DiagnosisMSC: NCLEX: Physiological Integrity
A client reveals that she induces vomiting as often as a dozen times a day. The nurse would expect assessment findings to support which electrolyte imbalance? Hypernatremia Hypokalemia Hypercalcemia Hypolipidemia
Hypokalemia Vomiting causes loss of potassium, leading to hypokalemia. Vomiting is not the trigger for any of the other options presented.REF: 344
A client has a history of demonstrating aggression physically. What short-term goal will best help the client manage this anger? Strike objects rather than people. Limit aggression to verbal outbursts. Isolate in lieu of striking people. Identify situations that precipitate hostility.
Identify situations that precipitate hostility. The identification of situations that create hostile feelings must occur if the client is to develop new coping strategies. All the remaining options only suggest limiting the anger.REF: 514; Box 27-5
A client who is 16 years old, 5 foot, 3 inches tall, and weighs 80 pounds eats one tiny meal daily and engages in a rigorous exercise program. Which nursing diagnosis addresses this assessment data? Death anxiety Ineffective denial Disturbed sensory perception Imbalanced nutrition: less than body requirements
Imbalanced nutrition: less than body requirements A body weight of 80 pounds for a 16-year-old who is 5 foot, 3 inches tall is ample evidence of this diagnosis. There is no support in the data as presented to justify any of the other nursing diagnoses.REF: 337
Which assessment findings are associated with approaching death? Select all that apply. Increased drowsiness Increased blood pressure Progressive weakness Decreased heart rate Loss of appetite
Increased drowsiness Progressive weakness Loss of appetite The process of dying varies based upon the underlying cause. Some general signs of approaching death include growing weakness, loss of appetite, and increased drowsiness, an increase in heart rate, and a decrease in blood pressure.REF: 558-559
An adolescent male is swearing and shouting at his physician who refused to give him a pass to leave the unit. What is the primary importance of this behavior? It is acceptable if directed at staff but not when directed at other clients. It may reduce tension and prevent the client from physically acting out. It is a major indicator that the client may become physically aggressive. It can be attributed to lack of parental controls applied at an early age.
It is a major indicator that the client may become physically aggressive. Physical aggression is preceded by anger, which may be expressed by swearing and shouting, pacing, and other menacing behaviors. It is not acceptable behavior regardless of its focus nor is it generally associated with a lack of parental controls. The release of tension is not the focus of this question.REF: 507; Box 27-1
When educating a client diagnosed with bulimia nervosa about the medication fluoxetine, the nurse should include what information about this medication? It will reduce the need for cognitive therapy. It will be prescribed at a higher than typical dose. There are a variety of medications to prescribe if fluoxetine proves to be ineffective. Long-term management of symptoms is best achieved with tricyclic antidepressants.
It will be prescribed at a higher than typical dose. Research has shown that antidepressant medication together with cognitive-behavioral therapy brings about improvement in bulimic symptoms. Fluoxetine (Prozac), an Selective serotonin reuptake inhibitors (SSRI) antidepressant, has FDA approval for acute and maintenance treatment of bulimia nervosa in adult patients. When fluoxetine is used for bulimia, it is typically at a higher dose than is used for depression. Although no other drugs have FDA approval for this disorder, tricyclic antidepressants helped reduce binge eating and vomiting over short terms.DIF: Cognitive Level: Analyze (Analysis)REF: page 29TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity
A client reports insomnia and shares that a friend has recommended a nonprescription hormone product that can be purchased at the local health food store. The nurse suspects that the medication contains which component? A benzodiazepine A tranquilizer Melatonin Lithium
Melatonin The use of melatonin appears to be helpful in treating sleep problems in the elderly. However, this practice is not without risk. Melatonin products are not approved by the U.S. Food and Drug Administration; therefore, variation may exist in the purity, safety, and effectiveness of the products. None of the other options can be purchased over the counter.REF: 368
A nurse attempts to intervene verbally when an angry client initially threatens to throw a chair but quickly focuses the anger toward the nurse. Several staff members gather behind the nurse, but then the client shouts, "I will calm down when that nurse isn't in my face." The nurse best demonstrates the ability to help the client deescalate by implementing which intervention? Continuing to manage the situation personally. Telling the client, "It isn't safe for me to leave the room." Moving outside of the client's personal space. Apologizing for upsetting the client.
Moving outside of the client's personal space. There is no need for the nurse to stand her ground to save face. The goal is to deescalate the situation. When the client makes a request that can be met without compromising safety, granting the request is acceptable. None of the other options are addressing the client's reasonable request.REF: 509; Box 27-2
Which ethical concept regarding client care poses the greatest concern for a nurse providing end-of-life care for a client considering euthanasia? Nonmaleficence Beneficence Autonomy Individual liberty
Nonmaleficence An ethical concept relevant to euthanasia is that of nonmaleficence, or doing no harm and considering whether helping to end life is an act of harm. None of the other ethical concepts is as directly related to the actions of nursing at the end of a client's life.REF: 556
An older adult client is reporting symptomatology that suggests REM sleep behavior disorder (RSBD). Which comorbid condition should the nurse assess for? Lymphoma Hypertension Acute renal failure Parkinson's disease
Parkinson's disease RSBD is seen in elderly males as they begin to develop neurological pathologies such as Parkinson's disease. None of the other options are directly associated.REF: 363
Which statement is true of the eating disorder referred to as bulimia? Patients with bulimia often appear at a normal weight. Patients with bulimia binge eat but do not engage in compensatory measures. Patients with bulimia severely restrict their food intake. One sign of bulimia is lanugo.
Patients with bulimia often appear at a normal weight. Patients with bulimia are often at or close to ideal body weight and do not appear physically ill. The other options do not refer to bulimia but rather refer to signs of binge eating disorder and anorexia nervosa.DIF: Cognitive Level: Understand (Comprehension)REF: page 6TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity
A slightly obese client reports falling asleep during the daytime even though she has slept all night. Her husband says she snores, and her blood pressure is noted to be in the low hypertensive range. The nurse anticipates that the client will be scheduled for which diagnostic test? Hypertension screening Polysomnography Glycosylated hemoglobin Positron emission tomography
Polysomnography Polysomnography consists of an electroencephalogram that records respirations, eye movements, and muscle tone during sleep. Sleep apnea becomes apparent if respirations cease frequently during sleep. None of the other options are focused on these behaviors.REF: 359-360
Which document allows an individual to appoint another person to make health care-related decisions for them if they become unable to do so for themself? Advance directive Living will Do not resuscitate request Power of attorney for health care
Power of attorney for health care A medical or healthcare power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care if you are unable to do so. An advance directive may include a living will, that may include the request not to resuscitate, and/or a power of attorney for health care.REF: 557
A client has been placed in seclusion to control aggressive behavior. Nursing care while the client is in mechanical restraints should include which intervention? Observation every 30 minutes Releasing the client every 8 hours Increasing sensory stimulation Providing regularly scheduled nutrition and hydration
Providing regularly scheduled nutrition and hydration Clients must be given meals on schedule and frequently offered cold liquids in paper cups (at least every 2 hours; hourly if the client is highly hyperactive). None of the remaining options present accurate information about the management of a client in mechanical restraints.REF: 512; Box 27-3
What non-habit-forming melatonin receptor agonist is often prescribed for insomnia? Zolpidem (Ambien) Ramelteon (Rozerem) Eszopiclone (Lunesta) Zaleplon (Sonata)
Ramelteon (Rozerem) Ramelteon (Rozerem) is a short-acting melatonin receptor agonist that has been approved by the FDA for insomnia and is not habit forming.REF: 368; Table 19-2
Which diagnosis from the list below would be given priority for a client diagnosed with bulimia nervosa? Disturbed body image Chronic low self-esteem Risk for injury: electrolyte imbalance Ineffective coping: impulsive responses to problems
Risk for injury: electrolyte imbalance The client who engages in purging and excessive use of laxatives and enemas is at risk for metabolic acidosis from bicarbonate loss. This electrolyte imbalance is potentially life threatening. While appropriate none of the other options are as likely to risk the client's life.REF: 343
Which nursing diagnosis is the priority when planning care for a client who displays considerable anger and occasional aggression? Social isolation Risk for other-directed violence Ineffective coping: overwhelmed Ineffective coping: maladaptive
Risk for other-directed violence Risk for other-directed violence is the priority diagnosis. The nurse then must determine which of two other diagnoses—ineffective coping: overwhelmed or ineffective coping: maladaptive—is appropriate. Social isolation is not an initial concern.REF: 508
Biological theorists suggest that the cause of eating disorders may be related to which factor? Normal weight phobia Body image disturbance Serotonin imbalance Dopamine excess
Serotonin imbalance The selective serotonin reuptake inhibitors have been shown to improve the rate of weight gain and reduce the occurrence of relapse. None of the remaining options are currently supported by any biological theories.REF: 335
A client reports to the nurse that falling asleep can often take hours. Which intervention should the nurse implement? Teach the client how to do progressive relaxation. Advise the client to drink an ounce or two of brandy at bedtime. Suggest that the client seek a referral for polysomnography. Point out that reducing stress at work would be advisable.
Teach the client how to do progressive relaxation. Progressive relaxation relaxes muscle groups sequentially and generates a state of pleasant comfort and ease, a natural prelude to sleep. It is inappropriate to encourage the use of alcohol as a sleep aid since it is known to decrease stage 3 sleep. A referral for a sleep test is premature. While stress reduction is appropriate, concentrating only on work-related stress is not effective.REF: 367
The nurse working with clients diagnosed with eating disorders can help families develop effective coping mechanisms by implementing which intervention? Teaching the family about the disorder and the client's behaviors Stressing the need to suppress overt conflict within the family Urging the family to demonstrate greater caring for the client Encouraging the family to use their usual social behaviors at meals
Teaching the family about the disorder and the client's behaviors Families need information about specific eating disorders and the behaviors often seen in clients with these disorders. This information can serve as a basis for additional learning about how to support the family member. While the other options may be appropriate for specific client families, they are not as fundamental as the correct option.REF: 337
A client asks the nurse to explain what basal sleep requirement is. What is the nurse's best response? The basal temperature of your body needed to induce the best sleep. The sleep time by your body needed to repair cellular damage. The amount of sleep needed to be fully awake and perform well in the daytime. The amount of sleep needed to transition to rapid eye movement (REM) sleep.
The amount of sleep needed to be fully awake and perform well in the daytime. Basal sleep requirement is the amount of sleep required to feel fully awake and able to sustain normal levels of performance during the periods of wakefulness. The other options do not describe basal sleep requirement.DIF: Cognitive Level: Apply (Application)REF: page 4TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity
A 21-year-old client asks the nurse, "What's wrong with my brain causing me to be so angry and aggressive?" The nurse's response should be grounded on what research-supported basis? The diminishment of stress hormones causes anger and aggression. No abnormalities of the brain have been identified that correlate with anger and aggression. The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. Personality type plays a much greater part in anger and aggression than physical factors.
The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. Research has supported the theory that the brain's limbic system and prefrontal cortex as well as some neurotransmitters play a part in anger and aggression. None of the other options are supported by current research.DIF: Cognitive Level: Apply (Application)REF: pages 4, 5TOP: Nursing Process: ImplementationMSC: NCLEX: Psychosocial Integrity
A dying client's family is concerned that the opioid pain medication being prescribed will hasten the client's death. Why? The Rule of Double Effect (RDE) prevents the use of opioids to facilitate a client's death. There is little research evidence to support that appropriate opioid management will result in an earlier death. Pain management for the terminally ill is the primary concern of the health care team. Addition to the opioid is a greater risk than is the possibility of a premature death.
There is little research evidence to support that appropriate opioid management will result in an earlier death. Pain is sometimes undertreated because the patient and/or family is concerned about sedation, addiction, and/or hastening the demise of their loved one. The RDE is a bioethical principle that allows a physician or APRN to make a decision, such as prescribing adequate pain medication, even though the pain medication might cause the patient to die sooner. There is little evidence, however, to support the concern that appropriate use of opioids will hasten death.DIF: Cognitive Level: Apply (Application)REF: page 13TOP: Nursing Process: PlanningMSC:NCLEX: Safe and Effective Care Environment
What older concept of care is being used currently to help in violence reduction in disruptive clients? Aired grievances Trauma-informed care Shared governance Learned helplessness
Trauma-informed care Trauma-informed care is an older concept of providing care that has been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patients' past experiences of violence or trauma and the role it currently plays in their lives. None of the other options refer to a care concept that helps reduce violence.DIF: Cognitive Level: Understand (Comprehension)REF: page 9TOP: Nursing Process: PlanningMSC: NCLEX: Psychosocial Integrity
Nurses coping with angry clients may find it helpful to remember that anger and aggression begin as feelings of which personal characteristic? Isolation Confidence Hopelessness Vulnerability
Vulnerability The progression is vulnerability, perception of event as a threat, arousal, and then uneasiness and anxiety. Anger is not as influenced by any of the other options.REF: 507
Which intervention would be least useful for accurate assessment of the weight of a client diagnosed with anorexia nervosa? Weigh 2 times daily first week, then three times weekly. Weigh fully clothed before breakfast. Do not reweigh client when client requests. Permit no oral intake before weighing.
Weigh fully clothed before breakfast. Clients should be weighed daily first week, then three times weekly wearing only bra and panties or underwear before ingesting any food or fluids in the morning. Reweighing is not a request that should be afforded to the client.REF: 340-341
After stabilization of symptoms, what is the primary focus of treatment for a client diagnosed with anorexia nervosa? Weight restoration Improving interpersonal skills Learning effective coping methods Changing family interaction patterns
Weight restoration Weight restoration is the priority goal of treatment for the client with anorexia nervosa because health is seriously threatened by the underweight status. The other options are addressed are secondary to the physiological goal of weight restoration.REF: 338
An angry client frequently loses patience with the nurses and shouts at them while they perform a complicated dressing change. Which plan could they create to intervene effectively in this behavior that focuses on behavior therapy concepts? Telling him they will not change his dressing if he is going to abuse them. When the client begins to become abusive, the nurse suggests returning in 20 minutes when he has regained control. Assuring him they will complete the dressing change as quickly as possible. Explaining that they are professionals and unused to being shouted at by people they are trying to help.
When the client begins to become abusive, the nurse suggests returning in 20 minutes when he has regained control. The nurse is using behavioral techniques to reinforce desirable behavior (spending time with the client when he is calm) and limit reinforcement of undesirable behavior (leaving when he is acting out anger). None of the other options demonstrates behavior therapy.REF: 511, 515
Which of the following are myths surrounding rape? Select all that apply. Women are usually raped by a stranger. Women do not "ask" to be raped by their behavior or dress. Most rapes occur away from home areas such as alleys and behind buildings. Documented rape cases include women from 8 to 70 years old. Rape is an expression of aggression and anger. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. Unless the assailant is armed, most women should be able to get away and avoid the rape.
Women are usually raped by a stranger. Most rapes occur away from home areas such as alleys and behind buildings. Documented rape cases include women from 8 to 70 years old. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. Unless the assailant is armed, most women should be able to get away and avoid the rape. It is true that women do not "ask to be raped" by behaving or dressing in a particular manner. The other options are untrue statements.DIF: Cognitive Level: Analyze (Analysis)REF: page 14 (Table 29-4)TOP: Nursing Process: AssessmentMSC: NCLEX: Safe and Effective Care Environment
What factors are consistently observed to increase the risk for sleep disturbances? Gender and race Diet and exercise alcohol and tobacco income and education
alcohol and tobacco There is a strong correlation between alcohol and tobacco use with sleep latency and efficiency problems. None of the other factors are as consistently observed as risk factors.REF: 367; Box 19-2
Assessment of a client suspected of experiencing bulimia nervosa calls for the nurse to perform a range of motion assessment. inspection of body cavities. inspection of the oral cavity. body fat analysis.
inspection of the oral cavity. Repeated vomiting often causes dental erosions and caries. None of the other options represent frequently engaged dysfunctional behaviors.REF: 343
