444 Psych Final

20. A new nurse asks the experienced nurse, Why did you ask about culture when it was obvious you needed to focus on the battering? The experienced nurse should respond: a. Its just a habit I got into awhile ago. b. It helps me focus on whether to do a complete physical assessment. c. Culture is a determinant of how women interpret and respond to violence. d. If I know more I can refer her to a shelter that caters to her cultural group.

C Understanding the womans culture not only helps understand how the woman will view and respond to violence but also is essential to developing an effective treatment plan. Some ethnic women are isolated and would not be able to seek assistance from police or community agencies. The remaining options are made-up responses and have no basis in theory or practice. DIF: Cognitive Level: Application REF: Page 531 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 19. Which statement by a patient with generalized anxiety disorder for whom lorazepam (Ativan) is prescribed as needed (prn) suggests the patient understands the purpose of the medication? a. I can talk with my therapist more easily after my medication takes effect. b. I wonder if I will have to take this medication for the rest of my entire life. c. Im embarrassed and dont want anyone to know Im on this kind of medication. d. Im going to ask for my prn dose so I can sleep instead of worrying about my kids.

A The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist. The remaining options show questions and inappropriate use of the medication. DIF: Cognitive Level: Application REF: Page 587 TOP: Nursing Process: Evaluation

3. Which behavior is supportive of a diagnosis of dependent personality disorder? a. Perceives personal behavior to be embarrassing b. Believes they are incapable of functioning independently c. Tends to exaggerate the potential dangers of ordinary situations d. Demands excessive attention from others whenever in a group situation

B The dependent person must rely on others to make decisions and assume responsibility of major areas of his or her life. Low self-esteem and exaggeration are seen in avoidant personality disorder. Attention seeking is seen in narcissistic personality disorder. DIF: Cognitive Level: Application REF: Page 307 TOP: Nursing Process: Assessment

27. When leading a therapeutic group, the nurse demonstrates an understanding of the need to act as the groups executive when: a. Restating rules when a new member joins b. Being available to orient the new members c. Helping a member defuse the anger they are experiencing d. Working with a member to help improve their communication skills

A Executive functioning refers to monitoring and attending to group rules and procedures. Caring demonstrates expressions of kindness. Meaning attribution includes accepting of feelings, although emotional stimulation would reflect working communication skills. DIF: Cognitive Level: Application REF: Page 609 TOP: Nursing Process: Planning

3. A substance use disorder (SUD) is a likely comorbid mental illness in which patient? a. The soldier diagnosed with posttraumatic stress disorder b. The teenager demonstrating symptoms of poor impulse control c. The older adult diagnosed with early stage Alzheimers disease d. The new mother exhibiting symptoms of postpartum depression

A Posttraumatic stress disorder creates a risk for substance use or relapse. A total of 30% to 60% of persons with SUDs meet the criteria for comorbid posttraumatic stress disorder. The remaining options have not shown such a prevalence of comorbid relationship with SUDs. DIF: Cognitive Level: Application REF: Page 327 TOP: Nursing Process: Assessment

16. A patient has been diagnosed with Alzheimers disease, stage 1. The nurse would expect to help the family plan measures to assist the patient with: a. Perseveration b. Recent memory loss c. Catastrophic reactions d. Progressive gait disturbances

B Recent memory loss is the only symptom listed in the options that would be expected in stage 1 Alzheimers disease. DIF: Cognitive Level: Comprehension REF: Page 375 TOP: Nursing Process: Planning

4. Which assessment findings describe risk factors that increase the potential risk for mental illness? Select all that apply. a. Possesses high tolerance for stress b. Is very curious about how things work c. Admits to being a member of an ethnic gang d. Only practicing Jew among school classmates e. Has a younger sibling who is mentally challenged

C, D, E Risk factors are internal predisposing characteristics and external influences that increase a persons vulnerability and potential for developing mental disorders. Types of risk factors and examples include the following: having a mentally-challenged family member in the home; belonging to a punitive gang; and being the object of reject or bullying. The remaining options are protective factors. DIF: Cognitive Level: Application REF: Page 11 TOP: Nursing Process: Evaluation

13. Which patient behavior would support the diagnosis of residual schizophrenia with negative symptoms? a. Communicating using only rhyming phases b. Claims that worms are crawling in my brain c. Maintaining both arms suspended awkwardly overhead d. Shows no emotion when telling the story of a sisters recent death

D Blunted affect is considered a negative symptom. The other symptoms would be classified as positive symptoms. DIF: Cognitive Level: Application REF: Page 274 | Page 280 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 21. What intervention will the nurse request for a patient reporting gastrointestinal side effects related to valproate therapy? a. Mild laxative b. Low-fat diet c. Oral antacid d. Histamine-2 antagonist

D Indigestion, heartburn, and nausea are common side effects of valproate therapy. The administration of a histamine-2 antagonist such as famotidine (Pepcid) is sometimes helpful. The other options would have no impact on the complaint. DIF: Cognitive Level: Application REF: Page 584 TOP: Nursing Process: Planning

22. Which intervention has highest priority for a patient with stage 3 Alzheimers disease? a. Cutting the patients food into bite size pieces b. Providing fluids to the patient every hour while awake c. Demonstrating to the patient how to put toothpaste on the brush d. Assisting the patient in signing a birthday care for a granddaughter

B The severe dementia characteristics of stage 3 renders the patient incapable of independently meeting hydration and nutrition needs. These needs are basic to life, so they are of highest priority. The remaining options are not applicable for such an impaired patient. DIF: Cognitive Level: Application REF: Page 375 TOP: Nursing Process: Implementation

16. The nurse who sees a number of battered elderly females each year decides to put together a set of guidelines for nurses. An appropriate guideline to include would be to: a. Make protective services aware of the abuse. b. Take at least two photographs of each trauma area. c. Begin the interview by asking the least sensitive questions. d. Assess for the presence of sexually transmitted diseases.

C During the assessment and when taking the womans history, it is recommended that in all cases the nurse begins with the least sensitive questions and gradually progress to the more sensitive ones. The remaining options may be appropriate but depend on the circumstances. DIF: Cognitive Level: Application REF: Page 531 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 36. A patient taking SSRIs mentions to the nurse that his current medication causes fewer side effects than the tricyclic antidepressant he took several years earlier. The nurse understands that SSRIs advantage is due to: a. Inhibiting both serotonin and norepinephrine uptake b. Selectively inhibiting dopamine uptake c. Blocking only serotonin reuptake d. Making more GABA available

C TCAs inhibit the reuptake of both norepinephrine and serotonin, producing more side effects than SSRIs that selectively block only serotonin reuptake. SSRIs do not affect dopamine or GABA availability. DIF: Cognitive Level: Application REF: Page 576 TOP: Nursing Process: Implementation

31. When a novice nurse asks why the unit has a multidisciplinary approach to therapeutic activities, the nurse should explain that multidisciplinary collaboration: a. Produces a higher level of insurance reimbursement b. Reduces the incidence of aggressive behavior by patients c. Produces quicker results and earlier discharge to the community d. Produces better outcomes than when only one perspective is used

D Broader input in problem identification and resolution enhances patient outcomes. The remaining options are either untrue or irrelevant. DIF: Cognitive Level: Application REF: Page 617 TOP: Nursing Process: Implementation

12. To provide nursing care to abused children and their families, the nurse must first: a. Recommend removal of the children from the family. b. Complete a comprehensive physical and mental assessment. c. Refer each case to the appropriate social worker for follow-up. d. Examine personal feelings regarding the trauma of child abuse and neglect.

D Self-examination is required in order for the nurse to be objective and therapeutic in providing care. Although important, an assessment is not the initial step in this situation. Removal is not always recommended. A social service referral may not be required, depending on the situation. DIF: Cognitive Level: Application REF: Page 537 TOP: Nursing Process: Implementation

15. Which behavior supports the failure to successfully achieve the oral stage of Freuds psychosexual stages of development? a. An adults excessive dependency on parents b. A history of multiple, simultaneous sex partners c. A need to ritualistically turn the lights off repeatedly d. A lack of guilt when responsible for mistreating others

A Individuals who have difficulty with the oral stage are often dependent. The other options reflect behavior not grounded in this stage. DIF: Cognitive Level: Application REF: Page 302 TOP: Nursing Process: Assessment

1. Which understanding is the basis for the nursing actions focused on minimizing mental health promotion of families with chronically mentally ill members? a. Family members are at an increased risk for mental illness. b. The mental health care system is not prepared to deal with family crises. c. Family members are seldom prepared to cope with a chronically ill individual. d. The chronically mentally ill receive care best when delivered in a formal setting.

A When families live with a dominant member who has a persistent and severe mental disorder the outcomes are often expressed as family members who are at increased risk for physical and mental illnesses. The remaining options are not necessarily true. DIF: Cognitive Level: Application REF: Page 3 TOP: Nursing Process: Planning

27. Therapeutic interactions between the nurse and a manic patient will be facilitated when the nurse: a. Uses a calm, matter-of-fact approach to structuring b. Focuses primarily on enforcing rigid limits on behaviors c. Implements a laissez-faire approach to the patients symptoms d. Encourages the patient to use humor and wit to redirect energy

A A calm, matter-of-fact approach minimizes patient need for defensiveness and minimizes power struggles. The use of rigid limit setting leads to power struggles and escalation of patient hyperactive, aggressive behavior. Structure and judicious limit setting are more therapeutic. A laissez-faire approach is nontherapeutic; manic patients usually need structure. Encouraging humor and wit is generally ineffective since patients with mania cannot maintain control of emotions and may shift from witty to angry in seconds. DIF: Cognitive Level: Application REF: Page 245 TOP: Nursing Process: Implementation

13. According to statistical research data, which of these children currently being followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse? a. A child who is 2 years old and has cerebral palsy b. A child who is 5 years old and has chicken pox c. A child who is 8 years old and has appendicitis d. A child who is 11 years old and has a fractured humerus

A At highest risk for fatal abuse are children under 3 years of age and those with disabilities. The remaining options do not present children meeting the criteria. DIF: Cognitive Level: Application REF: Page 529 TOP: Nursing Process: Assessment

26. How can the nurse encourage an extremely shy patient to participate therapeutically in a dance activity group? a. Offer to dance with the patient. b. Ask the patient if this is the first dance he has attended. c. Sit with the patient away from the group. d. Encourage another patient to ask him to dance.

A If trust has been established, the patient may feel safe enough to dance with the nurse. If trust has not yet been established, the patient will see the nurses invitation as demonstrating respect and reaching out to him. Either way, the action will encourage participation. The nurse should not make another patient responsible for this patients participation. The remaining options do not encourage participation. DIF: Cognitive Level: Application REF: Page 617 TOP: Nursing Process: Implementation

24. Which of the following nursing responses is an example of the therapeutic technique of empathizing? a. I think you may be finding this very difficult. b. I see you have been crying since your wife left. c. Help me to understand how this is affecting you. d. It sounds as if this is important to you.

A In an empathetic response the nurse exhibits warmth and acknowledges the patients feelings. Commenting on the patients crying is an example of the technique of making observations. Asking for help to understand is an example of seeking clarification. Finding importance is an example of reflection. DIF: Cognitive Level: Application REF: Page 70 TOP: Nursing Process: Implementation (Communication and Documentation)

6. Which statement by the patient would indicate the need for additional education regarding the prescribed lithium treatment regimen? a. I will restrict my daily salt intake. b. I will take my medications with food. c. I will have my blood drawn on schedule. d. I will drink 8 to 12 glasses of liquids daily.

A Patients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The patient should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity. DIF: Cognitive Level: Application REF: Page 246 | Page 250 TOP: Nursing Process: Evaluation

10. The patients family asks whether a diagnosis of Parkinsons disease creates an increased risk for any mental health issues. What question would the nurse ask to assess for such a comorbid condition? a. Has your father exhibited any signs of depression? b. Does your father seem to experience mood swings? c. Have you noticed your father talking about seeing things you cant see? d. Is your dad preoccupied with behaviors that he needs to repeat over and over?

A Serotonin and its close chemical relatives, dopamine and norepinephrine, are the neurotransmitters that are most widely involved in various forms of depression. Most researchers agree that the immediate cause of parkinsonism is a deficiency of dopamine and so a patient with Parkinsons disease should be monitored for depression, The other mental health disorders (bipolar disorder, hallucinations, and obsessive compulsive disorder) have not been connected to Parkinsons disease. DIF: Cognitive Level: Analysis REF: Pages 106-107 TOP: Nursing Process: Assessment

17. The patient tells the nurse, I thought my doctor understood me completely. Now, I hate him! He doesnt understand me at all. The nurse assesses the patients description of feelings about the physician as evidence of the use of: a. Splitting b. Dissociation c. Isolation of affect d. Projective identification

A Splitting is the inability to synthesize the positive and negative aspects of self and others. It manifests as idealization and devaluation. Definitions of the other defenses listed do not fit the description of the behavior in the scenario. DIF: Cognitive Level: Application REF: Page 304 TOP: Nursing Process: Assessment

4. A patient is being treated in the inpatient unit for paranoid delusions that his wife is unfaithful resulting in threats to get her for this whenever I get out. Which intervention to assure his wifes safety will his primary therapist include in the discharge plan? a. Sharing the threats he has made with his wife b. Requiring mandatory day hospital attendance c. Advising the patient that he needs continued outpatient services d. Informing the patient of the consequences of harming his wife

A The Tarasoff ruling established the necessity for a mental health professional treating a patient who threatens to harm another individual to warn the person against whom the threat is made. The remaining options are not directly related to affecting his wifes safety. DIF: Cognitive Level: Application REF: Page 172 TOP: Nursing Process: Planning

11. A patient whose history includes physically abusing his spouse and children has been admitted to the unit for alcohol and drug dependency. Which nurse will likely experience difficulty establishing a therapeutic relationship with this patient? a. The nurse who has experienced physical abuse b. The novice nurse who has never cared for an abuser c. The experienced nurse who has seen too many abusers d. The nurse who has been in treatment for abusing a spouse

A The therapeutic use of the self begins with knowing yourself. Knowing yourself is a complex and lifelong learning process. At the core of self-knowledge is the nurses ability to correctly identify his or her own negative or unresolved issues including family backgrounds, dynamic cultural and social issues, values, biases, and prejudices. Having been a victim of physical abuse places this nurse in a situation that can be very harmful to the development of an affective nurse-patient relationship. The novice nurse may lack some of the knowledge and experience necessary to be effective but is not a likely to have intruding biases and prejudices. The experienced nurse is more likely to have worked on the ability to provide effective care in spite of such experience with this type of diagnosis whereas, the nurse having been treated for the diagnosis is most likely to show empathy and caring. DIF: Cognitive Level: Application REF: Page 68 TOP: Nursing Process: Assessment (Communication and Documentation)

4. A nursing interview for a patient being admitted for depression reveals that the patient has been taking a benzodiazepine for anxiety for 3 years. Which actions by the nurse reflect an understanding of the effects of this classification of drugs? Select all that apply. a. The nurse asks how much of the drug the patient takes daily. b. The admitting physician is notified of the patients medication history. c. The nurse prepares to discuss the process of detoxification with the patient. d. The nurse suggests to the patient that the dosage is likely to be increased. e. The patient is interviewed regarding how well the anxiety has been controlled.

A, B, C Benzodiazepines are relatively safe and effective for short-term use to control the debilitating symptoms of anxiety. However, longer-term treatment with these drugs raises issues of tolerance, abuse, and dependence. The medication dosage would not be increased. The effectiveness of the medication is irrelevant but rather the length of the therapy is the prime concern. DIF: Cognitive Level: Application REF: Page 201 TOP: Nursing Process: Planning

1. Upon voluntary admission, the nurse will ensure that the patients rights are preserved. Which interventions are directly related to a patients civil right? Select all that apply. a. Arranging for the patient to vote in city election by absentee ballot b. Respecting the patients right to refuse a dose of a prescribed medication c. Arranging for the patient to have a private area in which to visit with friends d. Deferring to a patients expressed wish to not share a room with anyone else e. Changing the assignment because a patient doesnt like a particular staff member

A, B, C When individuals enter a mental health facility, they usually retain their civil rights, unless such rights are clearly restricted via the use of due process to certify that an individual lacks the capacity or competence to have them. These individuals retain the right to vote, refuse medication, and to have visitors. A private room and selecting of staff are not civil rights that all patients are entitled to. DIF: Cognitive Level: Application REF: Page 172 TOP: Nursing Process: Implementation

1. Which assessment data is supportive of a diagnosis of antisocial personality disorder? Select all that apply. a. Was reprimanded to a juvenile correction facility at age 14 b. Mother reports characteristic behaviors as early as age 7 c. Is below age-appropriate norms for both weight and height d. Patient states, I dont like school and skip whenever I feel like it. e. Has been admitted to a drug rehabilitation program twice in 4 years

A, B, E Patients diagnosed with antisocial personality disorder have a history of conduct disorders before the age of 15 years, prison or juvenile detention experiences, and substance abuse. There is no research that supports the remaining options as being characteristic of this disorder. DIF: Cognitive Level: Application REF: Page 307 TOP: Nursing Process: Assessment

2. The nurse is planning approaches to use to begin the establishment of the nurse-patient relationship. Which therapeutic communication techniques will be most useful to achieve this goal? Select all that apply. a. Attentively listening as the patient describes their obsessive compulsive rituals b. Asking the anxious patient if they have a plan for controlling their current anxiety c. Encouraging the depressed patient to come and talk with me whenever you want d. Sitting quietly in the room while the non-communicating patient unpacks their belongings e. Responding to the patients feelings of loss by stating, I know that must have made you very sad.

A, C, D, E Attentive listening, offering self, silence and empathy are all therapeutic communication techniques that are appropriate for use in the orientation stage of the nurse-patient relationship. Encouraging plan formulation is reserved for the working phase of the relationship. DIF: Cognitive Level: Analysis REF: Page 73 TOP: Nursing Process: Implementation (Communication and Documentation)

: Physiological Adaptation 20. What is the basis for the reduction in disturbed thought processes when a patient is administered haloperidol (Haldol)? a. Reduction in the number of brain cells that crave dopamine b. Dopamine receptors are blocked, making dopamine less available c. Dopamine receptors are enhanced, making more dopamine available d. Medication causes an increased cellular production of dopamine

B Excess dopamine is responsible for symptoms of psychosis such as delusions and hallucinations. Blocking dopamine receptors will result in reduction of primary symptoms. The other options do not reflect the action of typical antipsychotic medications. DIF: Cognitive Level: Comprehension REF: Page 266 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 5. When the nurse realizes that a patient diagnosed with schizophrenia is not taking the prescribed oral haloperidol (Haldol), which intervention would promote medication compliance? a. Instructing the patient to have friends monitor his medications b. Beginning administration of haloperidol (Haldol) decanoate c. Writing instructions in detail for the patient to follow d. Changing haloperidol to an atypical antipsychotic

B Haloperidol decanoate is a depot medication, given intramuscularly every 2 to 4 weeks. It is unknown whether the patient has a support system. The patient probably received education, including written instructions prior to discharge. Changing to another classification of medication would not necessarily improve compliance. DIF: Cognitive Level: Application REF: Page 572 TOP: Nursing Process: Implementation

17. Which response is appropriate when a patients mother expresses guilt over causing my child to be schizophrenic? a. I can see how you would be upset over this turn of events. b. New findings suggest this disorder is biological in nature. c. Dont be so hard on yourself; your daughter needs you to be strong. d. Its difficult to see what produces stress for the child at the time its occurring.

B Many individuals in the mental health field attribute the development of schizophrenia to multiple causes centering on biological theories. The remaining options do little to provide the mother with new information. DIF: Cognitive Level: Application REF: Page 265 TOP: Nursing Process: Implementation

7. A depressed patient shares with the nurse that he, has been thinking about ending it all. Based on NANDA recommendations, the nurse: a. Implements suicide precautions for this patient b. Includes Risk for Self Harm to the patients care plan c. Documents regarding the patients safety every 15 minutes d. Reviews the patients chart for references to past incidences of hopeless

B NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet. The remaining options, although not inappropriate, do not related to NANDA. DIF: Cognitive Level: Application REF: Page 48 TOP: Nursing Process: Analysis

12. Which finding related to a teenager who has been diagnosed with depression is most significant when planning care? a. Her father recently remarried. b. Her mother died from suicide 1 year ago. c. She has expressed a dislike for her new stepmother. d. She ran away from home twice during the past month.

B Option b is correct because suicidal behavior can become a learned familial adaptation to stressors. Running away, remarriage, and issues in stepfamilies can be important, but they are not of primary importance. DIF: Cognitive Level: Analysis REF: Page 507 TOP: Nursing Process: Assessment

: Reduction of Risk Potential 36. In the ECT treatment preparation period the morning of treatment, the nurse should: a. Adequately hydrate the patient. b. Assess the patients cognitive function. c. Have the patient exercise for 10 minutes. d. Ensure that the patient produces a urine sample.

B Patient assessment is advisable to provide a baseline against which changes resulting from ECT can be measured. Although taking vital signs and performing other preparatory tasks, the nurse can assess orientation, immediate memory, thought processes, and attention span. The other options are interventions the nurse should not undertake. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Assessment

2. Which nursing activity shows the nurse actively engaged in the primary prevention of mental disorders? a. Providing a patient, whose depression is well managed, with medication on time b. Making regular follow-up visits to a new mother at risk for post-partum depression c. Providing the family of a patient, diagnosed with depression, information on suicide prevention d. Assisting a patient who has obsessive compulsive tendencies prepare and practice for a job interview

B Primary prevention helps to reduce the occurrence of mental disorders by staying involved with a patient. Providing medication and information on existing illnesses are examples of secondary prevention which helps to reduce the prevalence of mental disorders. Assisting a mentally ill patient with preparation for a job interview is tertiary prevention since it involves rehabilitation. DIF: Cognitive Level: Application REF: Page 4 TOP: Nursing Process: Implementation

28. When another patient serves as alter ego during an outpatient group session, the nurse documents that the group had been engaged in: a. Role-playing b. Psychodrama c. Cognitive therapy d. Consensus building

B Psychodrama uses spontaneous dramas to act out emotional problems to promote health through development of new perceptions, behaviors, and connections with others. Others in the group take the role of significant others. Role-playing and cognitive therapy do not use the technique of alter egos. Consensus building is not a form of therapy. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Assessment

22. A patient who has shown good progress with treatment has shown great resistance to being discharged to an outpatient program. Based on an understanding of the underlying pathology of resistance, the nurse: a. Recognizes that the behavior will cease when discharge has occurred b. Refers back to the patients progress as an indication of the patients strengths c. Assures the patient that outpatient therapy services will continue to be supportive d. Shares that although scary, discharge to outpatient therapy is a sign of improvement

B Resistance to change is part of human nature that both the nurse and the patient need to address and manage so that positive growth will occur. The nurse helps patients to overcome resistance by pointing out their progress and strengths. DIF: Cognitive Level: Application REF: Page 78 TOP: Nursing Process: Implementation (Communication and Documentation)

11. A community health nurse is working with a family in which an elderly woman was neglected by her son and his wife but insists on remaining with the young couple despite the threat of future neglect. Which intervention should be given highest priority? a. Identifying community resources to decrease the caregivers stress b. Establishing patient rights and consequences of abuse and monitoring c. Providing stress management techniques for both of the caregivers d. Educating the caregivers on the aging process and how to cope with it

B Securing the patients safety is the priority for care. This option sets forth expectations for the family and establishes the fact that the patients state will be monitored. The other options are appropriate interventions but are not the highest priority. DIF: Cognitive Level: Analysis REF: Page 545 TOP: Nursing Process: Planning

7. At admission, the nurse learns that some time ago the patient had an infarct in the right cerebral cortex. During assessment, the nurse would expect to find that the patient: a. Demonstrates major deficiencies in speech b. Is unable to effectively hold a spoon in the left hand c. Has difficulty explaining how to go about using the telephone d. Cannot use his right hand to shave himself or comb his own hair

B The cerebral hemispheres are responsible for functions such as control of muscles. The right hemisphere mainly controls the motor and sensory functions on the left side of the body. Damage to the right side would result in impaired function on the left side of the body. The motor cortex controls voluntary motor activity. Brocas area controls motor speech. Cognitive functions are attributed to the association cortex. The right side of the bodys motor activity is controlled by the left cerebral cortex. DIF: Cognitive Level: Application REF: Page 99 TOP: Nursing Process: Assessment

13. A nurse shows the best understanding of the legal importance of the patients chart when stating: a. You always document in ink and never erase or use white out in the nursing notes. b. Its a document that shows proof that the patient received care that met the expected standards. c. Patient charts are carefully protected from unlawful access by inappropriate individuals or institutions. d. The patient has a legal right to the information contained in the chart but not the original documentation itself.

B The patients chart is a legal document that effectively communicates patient outcomes, medications, treatments, responses, and unusual incidents reflecting the healthcare systems attempts at meet the standard of care appropriate for this patient. The other options are not as inclusive in describing the legal status of the chart. DIF: Cognitive Level: Application REF: Page 56 TOP: Nursing Process: Implementation; (Teaching and Learning)

: Pharmacological and Parenteral Therapies 11. Which statement made by a patient who will be maintained on lithium following discharge will require further instruction by the nurse? a. I will have my blood work done regularly. b. When I get home, I may go on a salt-free diet. c. I have learned not to restrict my intake of water. d. I understand some people gain weight on lithium.

B This statement shows that the patient does not understand the relationship between lithium and sodium. The patient must be taught that changing dietary salt intake will affect lithium levels. Adding salt can cause lower levels; reducing salt can result in toxicity. The remaining options reflect correct information regarding lithium therapy. DIF: Cognitive Level: Application REF: Page 584 TOP: Nursing Process: Evaluation

4. A patient expresses a sense of genuineness in the nurse providing care when sharing with family members that: a. I believe the nurse can feel what Im feeling. b. I always know what the nurse expects of me; the explanations are always clear. c. I can tell the nurse is sincere because the face supports what the mouth is saying. d. I may not always like what the nurse has to say but I can always depend on what Im told.

C Genuineness is demonstrated by congruence between verbal and nonverbal behavior. Empathy is seeing things from the patients viewpoint. Clearly stating expectations is a characteristic of clarity. Trustworthiness can be described as dependability. DIF: Cognitive Level: Application REF: Page 69 TOP: Nursing Process: Implementation (Communication and Documentation)

: Pharmacological and Parenteral Therapies 30. Which nursing measure would be relevant to protecting the physiologic integrity of a patient during a manic episode when marked hyperactivity is present? a. Provide appropriate attire for patient to wear. b. Set firm limits on behavior injurious to others. c. Monitor the patients weight at the same time daily. d. Use genuineness to develop a therapeutic alliance with the patient.

C Hyperactivity expends huge amounts of calories and interferes with caloric intake, thus resulting in rapid weight loss. Monitoring weight daily protects the patients physiologic integrity. The other options are concerned with psychosocial integrity. DIF: Cognitive Level: Analysis REF: Page 245 TOP: Nursing Process: Assessment

5. When a patient diagnosed with borderline personality disorder experiences the death of a beloved parent, which characteristic response will the nurse anticipate? a. Denies the death for a protracted period of time b. Exhibits several different psychotic thought processes c. Expresses extreme anger and rage by burning the parents clothes d. Becomes uncharacteristically helpful and attends to the funeral arrangements

C If a significant person in the patients life dies, the patient with borderline personality disorder cannot mourn but often exhibits one or more of the six constituent states that include anger and rage. The other options are not characteristically seen as mourning behaviors in individuals with this diagnosis. DIF: Cognitive Level: Application REF: Page 304 TOP: Nursing Process: Assessment

20. A college-aged patient complains that, when I begin to take a test, I freeze up and my mind goes blank. The nurse will react based on the understanding that this patients anxiety level is: a. Mild b. Moderate c. Severe d. Panic

C In severe anxiety, a person may freeze and problem solving is difficult. A person is relatively relaxed and comfortable in mild anxiety. A person in moderate anxiety may feel energized and focused. A person at panic level has total loss of control. DIF: Cognitive Level: Comprehension REF: Page 189 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 2. The nurse would assess for neuroleptic malignant syndrome (NMS) if a patient on haloperidol (Haldol) develops a: a. 30 mm Hg decrease in blood pressure reading b. Respiratory rate of 24 respirations per minute c. Temperature reading of 104 F d. Pulse rate of 70 beats per minute

C Increased temperature is the cardinal sign of NMS. This BP is not a significant feature of NMS. There are no significant findings to support the options related to respirations or pulse rate. DIF: Cognitive Level: Application REF: Page 570 TOP: Nursing Process: Assessment

4. Which nursing intervention will assist a patient being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence? a. Allowing the patient to initiate the topic of violence b. Speaking with the patient in the absence of her husband c. Providing a safe, nonintimidating, and supportive environment d. Interviewing her in the presence of another healthcare professional

C Providing a safe environment is the first step in assisting a patient who is a victim of domestic violence. Including others in the conversation may increase anxiety and reluctance to disclose. Isolating the husband is assumed in providing a safe, nonintimidating environment. The patient may not disclose without prompting by the nurse. DIF: Cognitive Level: Application REF: Page 534 TOP: Nursing Process: Assessment

32. An elderly patient who lives with her daughter, son-in-law, and their three children reveals that her daughter sometimes slaps her when she does not move fast enough or spills things. The daughter states, I have so much to do that I become frustrated when my mother cant move fast enough or causes me extra work. The nurse caring for the mother could appropriately suggest: a. Moving the mother to an adult ambulatory care facility b. Employing an aide to provide care and stimulation for the mother c. Enrolling in a therapeutic group that addresses stress management d. Reading the elder law of the state to learn the penalties for elder abuse

C The daughter has many stressors and has few external supports. Enrolling in a stress management group would provide support as well as teach new adaptive coping strategies. Being required to read the law is threatening. The remaining options are premature. DIF: Cognitive Level: Application REF: Page 546 TOP: Nursing Process: Planning

23. Which activity therapy should the nurse recommend to the treatment team to assist the patient to relieve tension and achieve increased body awareness? a. Psychodrama b. Music therapy c. Dance therapy d. Recreation

C The large movements involved in dance therapy would enable the patient to relieve tension and move with greater body awareness and freedom. The other options will not promote body awareness. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Planning

33. A patient tells the nurse, When Im in the day room, I hear people whispering about me, and that makes me want to punch them. What direction will the nurse provide the staff regarding interacting with this patient? a. To minimize the need to whisper, utilize nonverbal techniques when possible. b. Stay physically close to this patient and use touch as a tool to interact with him. c. Treat this patient matter-of-factly. Be direct; dont talk about him or others in his presence. d. Interact with this patient only when necessary. The fewer interactions, the fewer misinterpretations there will be.

C This approach is important when providing care for a patient who is misinterpreting reality and is suspicious of the motives of others. Ostracizing the patient is non-therapeutic. Patients often misinterpret touch as threatening. This might promote loss of control. Using nonverbal communication techniques would be nontherapeutic as it would increase patient anxiety and promote loss of control. DIF: Cognitive Level: Application REF: Page 286 TOP: Nursing Process: Implementation

6. A nurse shows effective critical thinking skills directed towards nursing care of a cognitively impaired patient who continues to socially isolate by: a. Clearly stating that the patient must socially interact once daily b. Documenting that the patient continues to resist socialization c. Asking the patient to identify which unit activity they are willing to attend d. Suggesting that staff take the patient with them when running errands off the unit

D Critical thinking in this case involves the creation of alternative solutions to a problem that was not resolved by conventional methods. The remaining options, although not inappropriate, do not show critical thinking skills DIF: Cognitive Level: Application REF: Page 45 TOP: Nursing Process: Planning

9. The nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a patient believed to be exhibiting characteristics of a personality disorder? a. These patients are generally experiencing chronic depression and are severely impaired socially. b. A high stimulus environment will cause the patient to exhibit exacerbated behaviors that are loud and attention seeking. c. The patient is easily intimidated and may become so withdrawn that the assessment will be difficult if not impossible to complete. d. This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the patient feels threatened.

D Individuals with these disorders are often withdrawn, defensive, guarded, and impulsive, and may demonstrate an escalation of anger or make hostile or threatening comments. The remaining options are specific to certain types of personality disorders. DIF: Cognitive Level: Application REF: Page 309 TOP: Nursing Process: Implementation

23. Which intervention will the nurse caring for a patient suspected of phencyclidine (PCP) abuse implement based on an understanding of the medications unique properties? a. Assessing for chronic renal failure b. Focusing attention on providing patient safety c. Implementing suicide precautions immediately d. Monitoring for delayed development of psychotic symptoms

D Phencyclidine (PCP) is a hallucinogen, but it has its own set of CNS reactions. PCP has a long duration of action that can result in delayed psychotic symptoms. Chronic renal failure would not be immediately observable. Patient safety is a nursing responsibility regardless of the diagnosis. Self-harm is not generally a characteristic of this type of substance abuse. DIF: Cognitive Level: Application REF: Page 342 TOP: Nursing Process: Implementation

; Psychological Integrity 20. An appropriate nursing diagnosis for a patient who manifests a psychological problem through frequent expressions of unfounded or excessive guilt or shame, states that he is unable to deal with situations, and has a hesitation to try new things would be: a. Hopelessness b. Powerlessness c. Ineffective coping d. Chronic low self-esteem

D The behaviors mentioned in the situation are congruent with criteria for the diagnosis of chronic low self-esteem. The patients symptoms go beyond powerlessness. Hopelessness does not involve feelings of guilt and shame. The data is not consistent with a diagnosis of ineffective coping. DIF: Cognitive Level: Application REF: Page 47 TOP: Nursing Process: Analysis

22. Which factor has the greatest negative impact on the use of laboratory serum alcohol results in determining legal intoxication? a. The variable time it takes to metabolize alcohol in the body b. States differs greatly in their definitions of legal intoxication c. Legal issues with securing consent for the test from an impaired patient d. The relatively short period of time alcohol can be detected in the blood

D The major disadvantage of blood alcohol testing is the narrow window of time for the detection of drugs in the blood stream. Although the variability of individual metabolism rates may be considered a factor, they are stable enough to allow for testing timetables. The legal issues related to consent and the definition of legal intoxication limits does not impact the reliability of the test itself to determine intoxication. DIF: Cognitive Level: Application REF: Pages 347-348 TOP: Nursing Process: Assessment

2. When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED) whose family believes the patient to be a questionable historian due to cognitive impairment, the nurse initially begins the interview by: a. Reviewing the ED chart b. Contacting the admitting physician c. Directing the questions to the family members d. Establishing a line of communication with the patient

D The nurse should begin establishing the nursepatient relationship by initially directing the questions to the patient. The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options. DIF: Cognitive Level: Application REF: Page 40 TOP: Nursing Process: Assessment

: Reduction of Risk Potential 34. The physician has ordered atropine 0.5 mg intramuscularly (IM) for a patient to be administered 30 minutes prior to ECT. The rationale for use of this medication is that it reduces secretions and: a. Protects against vagal bradycardia b. Improves the scope of convulsive activity c. Reduces the need for recovery room staff d. Prevents incontinence of bladder and bowel

A Atropine is used for its ability to prevent vagal bradycardia associated with the electrical stimulus. The other options are neither relevant nor true. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 12. To educate a patient regarding what to expect following the administration of a benzodiazepine, the nurse must understand that benzodiazepines: a. Have a rapid onset of peak action b. Reduce availability of GABA c. Generally diminish the activity of GABA d. Interact with serotonin to increase availability

A Benzodiazepines do have a more rapid onset. There is no effect on the availability or function of GABA. Benzodiazepines do not diminish GABA activity; they enhance it. DIF: Cognitive Level: Application REF: Page 587 TOP: Nursing Process: Implementation

8. The nurse is attending a neighborhood meeting where a half-way house is being proposed for the neighborhood when a member of the community states, We dont want the facility; we especially dont want violent people living near us. The response by the nurse that best addresses the publics concern is: a. In truth, most individuals with psychiatric disorder are passive and withdrawn and pose little threat to those around them. b. The mentally ill seldom behave in the manner they are portrayed by movies; they are people just like the rest of us. c. Patients with psychiatric disorder are so well medicated that they do not display violent behaviors. d. The mentally ill deserve a safe, comfortable place to live among people who truly care for them.

A A major reason for the existence of the stigma placed on persons with mental illness is lack of knowledge. The main fear is of violence, although only a small percentage of patients with mental illness display this behavior. Providing the public with accurate information can help reduce stigma. The remaining options do not directly address the concerns stated. DIF: Cognitive Level: Application REF: Pages 13-14 TOP: Nursing Process: Implementation

5. A patient is admitted for treatment for persistent, severe anxiety. Which nursing diagnosis would help effectively direct patient care? a. Disturbed sensory perception related to narrowed perceptual field b. Risk for injury related to closed perception c. Hopelessness related to total loss of control d. Risk for other-directed violence related to combative behavior

A A narrowed perceptual field occurs with severe anxiety; therefore this diagnosis should be considered. Data are not present to support the other diagnoses. DIF: Cognitive Level: Analysis REF: Page 189 TOP: Nursing Process: Diagnosis

11. A patient has been admitted with disorganized type schizophrenia. The nurse observes blunted affect and social isolation. He occasionally curses or calls another patient a jerk without provocation. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The patients communication exhibits: a. A neologism b. Loose associations c. Delusional thinking d. Circumstantial speech

A A newly coined word having meaning only for the patient is called a neologism (meaning, new word). It is associated with autistic thinking. The patients speech does not show associative looseness or circumstantiality. The use of a neologism is not delusional in and of itself, but it suggests delusional thinking may be present. DIF: Cognitive Level: Comprehension REF: Page 278 TOP: Nursing Process: Assessment

12. Which verbal intervention would the nurse use when helping a patient who is experiencing severe to panic-level anxiety? a. I will stay with you to make sure you remain safe. b. First, you must stop pacing and wringing your hands. c. How can I help you get control of yourself and this anxiety? d. Can you tell me what was happening just before you got upset?

A A patient who is experiencing severe to panic-level anxiety requires brief, directive verbal interchanges aimed at increasing feelings of safety and security. It is not likely the patient will be able to stop the physical behaviors. Severely anxious patients are not able to evaluate their situation and give direction to the nurse or are they able to relate antecedent events to increasing anxiety. DIF: Cognitive Level: Application REF: Page 200 TOP: Nursing Process: Implementation

9. Which outcomes would be appropriate to determine early favorable response to antidepressant medication? a. The patient will complete own self-care activities. b. The patient will demonstrate assertive communication skills. c. The patient will describe signs and symptoms of major depression. d. The patient will make plans to attend one community social activity a week.

A Ability to manage basic ADLs demonstrates improvement in major depression. Understanding the disorder may occur later when patient cognition has improved enough to be able to process information. Initiation of community social activity occurs when the patient has increased energy. Assertive communication is learned and practiced after the depression lifts. DIF: Cognitive Level: Application REF: Page 253 TOP: Nursing Process: Evaluation

19. A patient attending group therapy mentions, In the beginning, I was so sick that everyone had to help me. For the last few days, its felt good to be able to give something back to the group. This statement can be assessed as an example of Yaloms factor of: a. Altruism b. Harmonizing c. Cohesiveness d. Imitative behavior

A Altruism refers to the experience of being helpful to others and is clearly what the patient is displaying in the scenario. The other factors are not applicable. DIF: Cognitive Level: Application REF: Page 610 TOP: Nursing Process: Assessment

10. A 15-year-old who shows poor impulse control and resistance to authority is prescribed outpatient therapy. The parents are insistent that the treatment include commitment to an inpatient facility. Which response by the nurse best supports the outpatient treatment modality? a. Your child has a right to receive treatment in the least restrictive manner. b. Outpatient therapy is better accepted by teens that are authority resistant. c. This form of treatment is less expensive and usually covered by insurance. d. Short-term therapy like this is usually done in an outpatient environment setting.

A An important concept related to the location and nature of mental health treatment is the concept of the least restrictive alternative; this involves providing mental health treatment in the least restrictive environment with the use of the least restrictive treatment. The remaining options do not reflect the criteria upon which appropriate care is based upon. DIF: Cognitive Level: Application REF: Page 169 TOP: Nursing Process: Implementation

12. A patient with borderline personality disorder is having difficulty with memories of sexual abuse and reports vague, generalized pains, menstrual problems, and headaches that severely impact her ability to function independently. Which collaborative consult will have the greatest impact on the patients health and wellness? a. Occupational therapist exploring ways to reduce stress b. Neurologist to evaluate the patients reports of headaches c. Acupuncturist exploring ways to reduce the generalized pain d. Gynecologist to assess the patients dysmenorrheal symptoms

A An occupational therapist can determine ways to increase adaptive functioning and independent living skills. Groups on stress reduction, self-awareness, and feelings are often co-led by occupational therapists. Although appropriate, the remaining options are all a result of unmanaged stress. DIF: Cognitive Level: Analysis REF: Page 314 TOP: Nursing Process: Planning

4. Which statement would the nurse use to describe the primary purpose of boundaries? a. Boundaries define responsibilities and duties to ones self in relation to others. b. Boundaries determine objectives of the various working stage of the relationship. c. Boundaries differentiate the assumed roles of both the nurse and of the patient. d. Boundaries prevent undesired material from emerging during the interaction.

A Boundaries are the social, physical, and emotional limits of the interaction. As such, they serve to define the responsibilities and duties of the nurse in relation to the patient. Objectives and roles are determined during the orientation stage. Emergence of undesired material may be a significant issue for the patient. DIF: Cognitive Level: Application REF: Page 615 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 16. An individual with poststroke depression is receiving an SSRI. What is the rationale for giving the medication at breakfast and again at midday? a. Prevent insomnia b. Prevent toxic reactions c. Decrease afternoon sleepiness d. Give an opportunity to monitor behavior closely

A CNS stimulants may cause insomnia if given late in the day. Toxicity is a result of excessive medication in the system, not when it is administered. The drowsiness resulting from SSRI use would not be minimized if taken as described. There is no expectation that resulting behaviors will need to be so closely monitored. DIF: Cognitive Level: Analysis REF: Page 578 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 10. Sertraline (Zoloft) has been prescribed for a patient with symptoms of a major depression. Which factor was probably most important in the physicians decision to use an SSRI? a. Good side-effect profile b. Less expense for the patient c. Increase in medication compliance d. Rapid rate of absorption from the GI tract

A Compared to other antidepressant medication groups, SSRIs have the best side-effect profile. SSRIs are more costly. No studies have shown that SSRIs result in better compliance. These drugs are absorbed slowly from the GI tract. DIF: Cognitive Level: Application REF: Page 578 TOP: Nursing Process: Planning

8. Which question would assist the nurse in determining whether the patient has been experiencing anxiety? a. Have you had difficulty concentrating lately? b. Have you been feeling sad and especially lonely? c. Do you have a history of failed personal relationships? d. Do you frequently experience difficulty controlling your anger?

A Concentration difficulties occur when moderate or greater levels of anxiety are present. Loneliness is more related to mood. A failed personal relationship is more related to poor self-esteem. Inability to control anger is related to poor impulse control. DIF: Cognitive Level: Application REF: Page 197 | Page 199 TOP: Nursing Process: Assessment

7. The nurse is determining whether the patients needs could be best met in a task or a process group. The decision is based on the understanding that a task group focuses on: a. Content issues b. The here and now c. Communication styles d. Relations among the members

A Content-oriented groups focus on goals and tasks of the group. Thus a task-oriented group would focus on content issues. Process groups focus on interpersonal relationships. Communication styles are not relevant to describing task-oriented groups. Here and now refers to dealing with issues that are taking place at the present time. DIF: Cognitive Level: Application REF: Pages 608-609 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 30. The nurse must notify the physician of the need to suspend treatment for a patient receiving clozapine (Clozaril) when the weekly WBC monitoring shows: a. WBCs below 2000/mm3 and absolute neutrophils below 1000/mm3 b. WBCs below 2500/mm3 and absolute neutrophils below 1500/mm3 c. WBCs below 3000/mm3 and absolute neutrophils below 2000/mm3 d. WBCs below 3500/mm3 and absolute neutrophils below 2500/mm3

A Counts at this level indicate the presence of leukopenia. Agranulocytosis is a possible side effect of Clozaril therapy for which the patient is closely monitored. The other levels are high enough to be considered safe. DIF: Cognitive Level: Application REF: Page 573 TOP: Nursing Process: Assessment

18. Which response demonstrates both empathy and understanding of the relationship genetics has to the development of schizophrenia in twins? a. In fraternal twins, the chance of the other twin developing the disorder is quite small. b. Studies show that 50% of twins develop schizophrenia when it is present in the other twin. c. No one can say what will happen, so we will hope for the best for you and both of your sons. d. You poor woman! I wish I could tell you that your other son he will be free of the disorder.

A Current research supports the correct option, whereas the remaining options are not factual and show expressed sympathy rather than empathy. DIF: Cognitive Level: Application REF: Page 266 TOP: Nursing Process: Implementation

14. An elderly patient was well until 12 hours ago, when she reported to her family that in the middle of the night she awakened to see a man standing at the foot of her bed. There is no evidence that this situation ever happened. This series of events supports which possible diagnosis? a. Delirium b. Anxiety c. Paranoia d. Dementia

A Delirium is a disturbance of consciousness and cognition that develops over a short period. It is secondary to a medical condition. The scenario does not fit the disorders mentioned in the remaining options. DIF: Cognitive Level: Comprehension REF: Page 371 TOP: Nursing Process: Assessment

17. A nurse is reprimanded by the nurse manager. Shortly thereafter, a patients family member reports that the nurse curtly told them You cant come in now. You know you need to wait until visiting hours. The incidence should be discussed based on the knowledge that the defense mechanism the nurse used was: a. Displacement b. Projection c. Sublimation d. Suppression

A Displacement is transferring a response or feeling toward one person onto another less threatening person. Projection is attributing strong faults to another and is not displayed in this scenario. Sublimation is channeling maladaptive thoughts into socially acceptable behaviors. Suppression is intentionally avoiding thinking about problem areas. DIF: Cognitive Level: Comprehension REF: Page 188 TOP: Nursing Process: Planning

19. A young, married female patient is attracted to a male nurse. When the nurse sets clear boundaries, the patient falsely accuses him of sexual harassment. The nursing supervisor recognizes the defense mechanism of: a. Projection b. Splitting c. Suppression d. Displacement

A Projection is attributing strong conflicting feelings to another person. Splitting is seeing others and oneself as all good or all bad. Suppression is incorrect because the person avoids thinking about problem areas. Displacement, or transferring a feeling to a less threatening person, is not being used in this scenario. DIF: Cognitive Level: Comprehension REF: Page 188 TOP: Nursing Process: Implementation

8. A patient who has been taking lithium carbonate 300 mg tid comes to the Outpatient Department with a list of medications he is taking. Which of the medications on the list would require re-evaluation of lithium dosage? a. HydroDIURIL daily b. Navane bid c. Ativan at bedtime d. Cefobid daily

A Diuretics alter fluid and electrolyte balance, increasing risk for lithium toxicity; therefore HydroDIURIL is correct. Antipsychotic medications are frequently prescribed concurrently with lithium to manage acute symptoms of mania, so no re-evaluation of lithium dose is necessary for Navane. Antianxiety drugs are not contraindicated with concurrent lithium use, so no lithium dose re-evaluation is necessary for Ativan. Antibiotics do not alter fluid and electrolyte balance, so readjustment of lithium dosage is not required for Cefobid. DIF: Cognitive Level: Analysis REF: Page 246 | Page 250 TOP: Nursing Process: Evaluation

28. A patient who is experiencing a manic episode approaches the nurse and with pressured speech states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. The priority nursing action is to: a. Measure the patients temperature and pulse. b. Offer to have the dietitian visit to discuss his diet. c. Tell the patient he can lead exercises at the community meeting. d. Show relief when the patient ends the interaction and walks away.

A During a manic episode, the patient may be inattentive to physical needs or illness. The brief remark about burning up could suggest fever. Thirst may accompany fever, be a sign of dehydration, or be related to lithium administration. More information is needed. Because hyperactive patients have difficulty remaining still, taking the temperature and pulse will give priority information. If necessary, BP can be taken later. A nutritional consult is not a priority intervention. It is not appropriate to foster increased hyperactivity. To show relief would be disrespectful on the part of the nurse. DIF: Cognitive Level: Application REF: Page 242 TOP: Nursing Process: Implementation

10. The nurse has been working with a patient who experiences anxiety. Which intervention should the nurse implement initially when the patient is observed pacing and wring her hands? a. Asking how she has managed anxiety effectively in the past b. Distracting her by offering to help her make a telephone call c. Asking her what she believes is causing her increased anxiety d. Teaching her to take deep, relaxing breaths to manage the anxiety

A First help the patient to build on the coping methods that the patient used to manage anxiety in the past. Coping methods that were previously successful will generally be effective in subsequent situations. Distraction is not usually successful initially. Assessing for the cause of the anxiety will not, in this situation, be helpful in managing it; often times patients are not aware of the cause. Teaching will not be effective while the patient is experiencing anxiety but should be done when the patient is relaxed and able to focus. DIF: Cognitive Level: Analysis REF: Page 200 TOP: Nursing Process: Implementation

6. The home care nurse is visiting a patient who was discharged to home after a procedure at an ambulatory surgical center. The patient lives alone in a senior retirement community. The nurses assessment documents mild dysphasia. The patient repeatedly asks, Why is there a bandage on my arm? and is not able to state the appropriate day and year. Appropriate planning for the patient should include: a. Assessing diet and meal preparation, assessing environment for safety problems, referral to a dementia program b. Attending English class to improve speech, transferring finances to a conservator, employing an aide to help with medications c. Arranging Meals on Wheels, attending speech therapy, relocation to a skilled nursing facility if no improvement in 1 month d. Arranging an appointment at a geriatric assessment program, OT referral for swallowing therapy, teaching to manage public transportation

A Further assessment is appropriate before making changes in the living environment. Enrolling in a dementia program will provide stimulation and help the patient maintain intellectual skills. English classes will not improve speech. The other plans might have relevance, however. The remaining sets of options are either irrelevant or beyond the patients abilities. DIF: Cognitive Level: Application REF: Page 383 TOP: Nursing Process: Planning

6. The patient was an awkward child who was ridiculed by his father for his inability to catch a ball. As an adult, the patient developed panic attacks at the time his company established after-work team sporting activities. Which data discussed during the nursing interview provides insight to the possible cause of this anxiety disorder when applying the behavioral model? a. He always avoids sports because Im short and not the least bit athletic. b. When in fifth grade, the patient caused his team to lose the big softball game. c. The company he works for places tremendous emphasis of successful team work. d. As a child he wore a leg brace that prevented him from participating in school sports.

A In behavioral models that are based on learning theory, the etiology of anxiety symptoms is a generalization from an earlier traumatic experience to a benign setting or object. As a result, he associates embarrassment and shame with sports events and develops panic attacks. The same kinds of cognitive operations that link embarrassment with sporting events link the cognition of the expectation of embarrassment with the idea of a sporting event, and the individual begins to experience panic attacks while merely thinking about being involved. The remaining options are not as likely to bring about the embarrassment and shame that would produce such a response. DIF: Cognitive Level: Application REF: Page 192 TOP: Nursing Process: Assessment

11. Which statement by an adult child concerning the behaviors of their parent supports the diagnosis of Alzheimers disease? a. Mom forgot to pay her utility bills last month. b. Mom isnt as interested in keeping a neat house as she was. c. Mom doesnt seem interested in going out with friends anymore. d. Mom refuses to stop driving even though her reaction time is very slow.

A Increased forgetfulness, particularly that involving former routine activities (such as bill paying), is symptomatic of Alzheimers disease. The other options do not indicate cognitive deficit. DIF: Cognitive Level: Application REF: Page 374 TOP: Nursing Process: Assessment

6. The nurse in the Emergency Department is taking a history from a family accompanying a child with suspicious traumatic injuries. The nurse should: a. Be open, concerned, and honest. b. Obtain information as covertly as possible. c. Avoid responding to hints that abuse has occurred. d. Separate the family from the child during the interview.

A The nurse serves as a role model for the parents and the child. Being open and honest and showing appropriate concern for the child is the most appropriate approach. Direct questioning is necessary to obtain the history. Concerns about the possibility of abuse must be addressed in a sensitive manner. The family will be able to remain with the child during history taking. It is helpful for the nurse to observe family interactions. DIF: Cognitive Level: Application REF: Page 541 TOP: Nursing Process: Assessment

5. When providing discharge teaching to a patient for whom English is a second language, what technique will the nurse use to assess the patients understanding of the information being shared verbally? a. Continuously evaluating the patients nonverbal cues b. Periodically asking the patient if they have any questions c. Asking the patient to repeat the information they are given d. Providing the information in concise, written form

A Individuals from different cultures or even different generations often misunderstand and misinterpret an unfamiliar language. Being aware of and critically examining cues that result from nonverbal responses is an excellent technique to check their interpretations. Asking if they have questions is an ineffective technique in light of the language barrier. Repeating the information is no guarantee that the patient understands the information. Providing the information in written form reinforces the material but does not ensure understanding especially if the patient has deficiencies related to reading the language. DIF: Cognitive Level: Application REF: Page 64 TOP: Nursing Process: Planning (Communication and Documentation)

: Reduction of Risk Potential 9. Which nursing intervention best demonstrates an understanding of the relationship between confirmed intravenous drug abuse and specific infections? a. Screening the patient for hepatitis B virus (HBV) b. Assessing the patient for potentially infected injection sites c. Determining if the patient has ever been tested for human immunodeficiency virus (HIV) d. Evaluating the patients understanding of the increased risk for developing sexually transmitted diseases

A Injecting drug users have one of the highest HBV rates among all risk groups and account for at least half of all new HCV cases, so screening for such infections demonstrates that the nurse understands the severity of the problem. Although the other options reflect potential infection risks, they are not as commonly seen in patients with this diagnosis. DIF: Cognitive Level: Application REF: Page 336 TOP: Nursing Process: Implementation

16. Which question is most appropriate when assessing a patient who is exhibiting symptoms of a systemic infection including a fever of unknown origin? a. Are you an intravenous drug user? b. Have you been told that you drink too much alcohol? c. Have you been diagnosed with an acute bacterial infection before? d. Are you familiar with an infection of the heart called endocarditis?

A Intravenous drug users are at risk for subacute bacterial endocarditis and other circulatory compromise created by foreign substances introduced during the process of intravenous use. Regardless of the setting, nurses need to ask about intravenous drug use whenever a patient presents with fever of unexplained origin. Assessing the patients knowledge related to bacterial infections and endocarditis will not address the possible cause of the fever. Alcohol consumption is not relevant in this situation. DIF: Cognitive Level: Application REF: Page 341 TOP: Nursing Process: Assessment

1. When asked, What causes alcoholism? the nurses response will be based on the fact that: a. The response to alcohol is a result of a brain-based disorder. b. Alcoholism is believed to be an allergic response to the alcohol. c. Every individual has the same susceptibility for developing alcoholism. d. It is a physical response to alcohol but its etiology is not fully understood.

A It has been determined that alcoholism is not an allergy but rather it is recognized as a partial brain-based disorder that some brains are more susceptible to than others. DIF: Cognitive Level: Application REF: Page 323 TOP: Nursing Process: Implementation

18. On day 4 of hospitalization after a suicide attempt, the patient tells the nurse, You dont have to worry about me any longer. Today was the turning point. You can stop the suicide precautions. Which action indicates the nurses use of intuition in responding to this patient? a. Reporting the patients statements and the nurses own feelings to the staff and suggest increased vigilance b. Reporting only the patients statements and evaluate the outcome, Patient will report lack of suicidal ideation as attained. c. Conferring with the patients family members to obtain their evaluation of the patient and his behavior and follow their lead d. Suggesting that the level of suicide precautions be lowered from one-to-one supervision to observing the patient every 30 minutes

A It is unlikely that a highly suicidal patient would recover so quickly. Sometimes hospitalization and medication allow a renewal of energy, enough to increase suicidal resolve. The nurse should follow this intuition and suggest increased vigilance. Keeping this concern to oneself is not helpful. Taking the lead from the family is not appropriate, and lowering suicide precautions so soon is risky. DIF: Cognitive Level: Application REF: Page 514 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 15. Which person with mania is the least likely candidate to receive lithium? The patient who is: a. Six weeks pregnant b. Recovering from a hysterectomy c. Taking hormone replacement therapy d. Displaying symptoms of postpartum depression

A Lithium is contraindicated during pregnancy because of teratogenic effects. The remaining options would not be contraindicative to lithium therapy. DIF: Cognitive Level: Application REF: Page 583 TOP: Nursing Process: Assessment

20. The individual who displays the history and symptoms most consistent with a medical diagnosis of seasonal affective disorder (SAD) is: a. 26 years of age and complains of 3 consecutive years of depressed mood beginning in November and remitting in April b. 64 years of age and complains of anhedonia, early morning awakening, psychomotor retardation, weight loss, and excessive feelings of guilt c. 46 years of age and complains of dysphoric mood for 3 years, poor concentration, loss of interest in social activities, indecision, low energy, and low self-esteem d. 38 years of age and complains of sadness, loss of ability to react to positive stimuli, weight gain, hypersomnia, leaden paralysis of limbs, and sensitivity to interpersonal rejection

A Marked seasonal changes in mood typify seasonal affective disorder. Depression begins in October or November and lifts in March or April and must occur for at least 2 consecutive years. The other options are lacking in the identifying period of time when the symptoms are exhibited. DIF: Cognitive Level: Application REF: Page 230 | Page 237 TOP: Nursing Process: Assessment

19. What information would serve as the basis for the nurses reply when asked whether the cycling of moods from depressed to manic is a constant pattern seen in bipolar disorders? a. Clinical observation tells us that mood disorders tend to remit and recur. b. Most cyclic behavior can be managed with the appropriate forms of therapy. c. Mood disorders generally see a decrease in cyclic affecting within 5 years of onset. d. Persons with higher cognitive abilities will generally exhibit fewer cyclic episodes.

A Mood disorders tend to remit and recur throughout the patients lifetime. There is no current research to support the other options. DIF: Cognitive Level: Application REF: Page 223 TOP: Nursing Process: Implementation

; Psychosocial Integrity 12. There remains a stigma attached to psychiatric illnesses. The psychiatric nurse makes the greatest impact on this sociological problem when: a. Providing educational programming for patients and the public b. Arranging for adequate and appropriate social support for the patient c. Assisting the patient to achieve the maximum level of independent functioning d. Regularly praising the patient for seeking and complying with appropriate treatment

A Much of the stigma attached to psychiatric illness is due to a lack of understanding of the biologic basis of these disorders. Therefore, effective patient, family, and public teaching is an important function of the role of the psychiatric mental health nurse. While the remaining options are appropriate, they are not directed towards eliminating social stigma but rather empowering the patient. DIF: Cognitive Level: Comprehension REF: Page 112 TOP: Nursing Process: Planning

9. A patient has been diagnosed with dementia secondary to cerebral disease. The family members note the patient has not been as sharp as he once was and that he has developed urinary incontinence and a gait disturbance. Which pathophysiology can cause such symptoms? a. Normal pressure hydrocephalus b. Vitamin B12 deficiency c. Hepatic disease d. Tuberculosis

A Normal pressure hydrocephalus is a disorder characterized by dementia, gait disorder, and urinary incontinence. Dilation of ventricles in the absence of increased CSF is a prominent manifestation. Early urinary incontinence is not seen in the disorders listed in the other options. DIF: Cognitive Level: Analysis REF: Page 367 TOP: Nursing Process: Assessment

7. Which statement by a young adult would alert the nurse to increased suicide risk? a. I have a necktie in my room that I can use to hang myself. b. If I fail one more class, Im going to have to think about ending it. c. When I leave home to live on my own, Im going to buy myself a gun. d. When I took two bottles of Moms pills, I had to have my stomach pumped.

A Only the correct option states an intended method and indicates immediacy and available means of enacting a successful suicide attack. DIF: Cognitive Level: Analysis REF: Page 510 TOP: Nursing Process: Assessment

21. The experienced nurse assessing a battered woman patient uses many open-ended questions during the interview. The rationale for this is that: a. The woman will feel more in charge of the interview. b. Patients cant refuse to answer when sensitive information is being probed. c. The questions are direct and easily understood by the anxious individuals. d. Such questions allow for simple yes or no answers when the patient is upset.

A Open-ended questions reflecting what the woman is disclosing give the patient the sense of being in control of the interview, and she is likely to reveal more than when direct questions are used exclusively. Open-ended questions are not easily answered yes or no. Open-ended questions are indirect. Patients can refuse to answer any question, so this is not an acceptable rationale. DIF: Cognitive Level: Application REF: Page 531 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 26. When reviewing the medications being taken by an elderly patient diagnosed with Alzheimers disease, the nurse should consult with the patients physician when noting a prescription for: a. Risperidone (Risperdal) b. Fluphenazine (Prolixin) c. Lorazepam (Ativan) d. Sertraline (Zoloft)

A Patients with dementia-related psychosis who were treated with atypical (second-generation) antipsychotics such as Risperdal were at an increased risk of death as compared with patient taking a placebo. The other medications are not currently known to have that risk. DIF: Cognitive Level: Application REF: Page 575 TOP: Nursing Process: Planning

5. An inappropriately dressed patient has not slept for 3 days while making excessive, expensive long-distance phone calls. When the patient can be heard singing loudly in the examining room, the nurse makes initial plans to focus on: a. Assessing needs for food, liquids, and rest b. Setting strict limits on dress and behavior c. Conducting an in-depth suicide assessment d. Obtaining a complete psychosocial assessment

A Patients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury. DIF: Cognitive Level: Application REF: Page 245 TOP: Nursing Process: Planning

20. Which self-reflective intervention is most appropriate for the nurse to engage in when managing care for patients who exhibit characteristics of personality disorders? a. Reinforcing the therapeutic boundaries between the nurse and patient as often as needed b. Requesting a temporary transfer to a medical unit periodically to help minimize burn-out c. Frequently self-assessing for biases and prejudices that result in patient care that is compromised d. Arriving at a personal decision regarding the use of both chemical and physical restraints to assure milieu safety.

A Patients with personality disorders have difficulty relating to others. As a consequence, these individuals have difficulty defining boundaries between themselves and others. Part of nursing care is to define boundaries within the therapeutic relationship in order to develop safe, patient-centered therapeutic relationships. The use of chemical and/or physical restraints is determined by institutional policies, not personal decision. The remaining options are appropriate for all patient care, not specifically care of patients with personality disorders. DIF: Cognitive Level: Application REF: Page 314 TOP: Nursing Process: Implementation

18. A patients wife has chronic alcoholism, and the husband is concerned about the possibility that their children may develop the disease. He asks the nurse what the risk is. The nurses best response is: a. The risk for developing alcoholism is increased if there is a family history of alcoholism. b. Studies have confirmed that individuals with dependent personality traits are at high risk for this disease. c. Cultures that include alcohol as part of the ritualized behavior have a higher rate of alcoholism. d. Twin studies have indicated that the environment of a person is more important than the biologic influences of parents.

A Problems with alcohol increase with the number of relatives with alcoholism. No unique personality profile is prone to addiction. Ritualized use of alcohol does not predispose to alcoholism and twin studies indicate a significant genetic contribution to susceptibility to alcoholism. DIF: Cognitive Level: Application REF: Page 327 TOP: Nursing Process: Implementation

11. A patient who has a history of bipolar disorder recently underwent orthopedic surgery and was discharged to return home. When visited by the home care nurse, the nurse documented the following: slow and soft speech; sad facial expression; and patient crying when describing extreme fatigue, low mood, and the feeling that he will never get well. He has refused to bathe and perform ADLs for several days. Which nursing diagnosis would be appropriate? a. Self-care deficit secondary to possible depression b. Situational low self-esteem related to immobility c. Deficient knowledge related to depression and surgery d. Disturbed thought processes related to bipolar disorder

A Refusal to perform tasks of bathing, grooming, and other ADLs provides evidence of a self-care deficit. The other symptoms documented by the nurse are characteristic of depression. No data are present to suggest the diagnoses given in the other options. DIF: Cognitive Level: Application REF: Page 245 TOP: Nursing Process: Diagnosis

27. A teenage boy has been periodically beaten by his father. The boy tells the nurse, Hell pay for this one way or another. The nurse treating his contusions should assess for behaviors suggesting: a. Aggression b. Depression c. Regression d. Withdrawal

A Research suggests that children who are abused are at high risk for antisocial behavior and associated aggressive behaviors for a period of at least 2 years after the battering incident. The boys remark is not consistent with any of the other options. DIF: Cognitive Level: Application REF: Page 538 TOP: Nursing Process: Assessment

3. What is the priority nursing diagnosis for a patient exhibiting signs of acute mania that include exaggerated physical activity, agitation, insomnia, and anorexia? a. Risk for injury b. Chronic low self-esteem c. Noncompliance d. Insomnia

A Risk for injury is the priority diagnosis. Possible injuries include dehydration, which may result from not drinking and trauma, which may result from bumping into objects or from physical altercations. The other options are valid diagnoses, but not of highest priority. DIF: Cognitive Level: Analysis REF: Page 242 TOP: Nursing Process: Diagnosis

25. The wife of a patient with moderate to severe dementia tells the nurse, Im exhausted. He wanders at night instead of sleeping, so I get no rest. Im afraid to leave him during the day, so I have to take him with me wherever I go. The nurse recognizes the need to provide teaching for this caregiver. An appropriate outcome for this teaching would include: a. Experiences less stress indicated by improved sleep patterns b. Feels comfortable leaving the patient in the care of others occasionally c. No longer experiences resentment concerning the need to care for the patient d. Feels at peace with the decision to admit the patient to an appropriate care facility

A Stress reduction allowing for better rest is an appropriate outcome. The other options are not necessarily appropriate nor will they result in improvement for the caregiver. DIF: Cognitive Level: Application REF: Page 388 TOP: Nursing Process: Implementation

18. Which symptom reported by an adult patient, who was sexually abused as a child, reflects the diagnosis of posttraumatic stress disorder (PTSD)? a. A history of substance abuse b. Refusing to go to public places from which escape may be difficult c. Seeking advice and guidance prior to making any significant decision d. Ruminating easily concerning the abuse with friends and acquaintances

A Substance abuse to help manage the unpleasant symptoms is characteristic of PTSD. Being uncomfortable in certain locations refers to agoraphobia. Seeking extensive support characterizes a dependent person. Ease in talking about the experience is uncharacteristic of PTSD. DIF: Cognitive Level: Application REF: Page 537 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 4. Which behavior displayed by a patient receiving a typical antipsychotic medication would be assessed as displaying behaviors characteristic of tardive dyskinesia (TD)? a. Grimacing and lip smacking b. Falling asleep in the chair and refusing to eat lunch c. Experiencing muscle rigidity and tremors d. Having excessive salivation and drooling

A TD manifests as abnormal movements of voluntary muscle groups after a prolonged period of dopamine blockade. Movements may affect any muscle group, but muscles of the face, mouth, tongue, and digits are commonly affected. Falling asleep is reflective of the sedative effect of these medications. Muscle rigidity and drooling reflect EPS caused from imbalance between dopamine and acetylcholine. DIF: Cognitive Level: Application REF: Page 570 TOP: Nursing Process: Assessment

23. A patient admitted with the diagnosis of schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the patient will: a. Be scheduled for a magnetic resonance imaging (MRI) test b. See a mental health specialist for extensive psychological testing c. Have an immunologic assay performed within 2 days of the admission d. Participate in a dexamethasone suppression test (DST) administered by the staff

A The MRI will reveal structural changes in the brain that might be responsible for symptoms of psychosis (e.g., abscess, tumor). Psychologic testing may be performed but will be less definitive in ruling out organic pathology. Immunologic studies are not indicated. The DST is related to depression. DIF: Cognitive Level: Application REF: Page 269 TOP: Nursing Process: Implementation

8. A nurse planning a group to help batterers learn more effective ways to cope would teach participants that the key component in wife battering is: a. Their need for the batterer to control b. The role of alcohol in the pattern of abuse c. History of psychotic or paranoid behavior d. Failure of the woman involved to assert herself

A The batterer uses violence as a means of controlling his partner to meet his own needs. Alcohol use is not the root cause of spousal abuse. There are no data to support mental illness as a factor in abusive relationships. Assertive behavior may result in increased abuse. DIF: Cognitive Level: Application REF: Page 528 TOP: Nursing Process: Planning

26. The care plan for a battered woman will be most successful if the nurse: a. Empowers the patient to make her own decisions b. Develops the plan and presents it to the woman c. Obtains photo evidence of the battery for use in court d. Has a family conference and mediates among the parties

A The nurses attitudes, values, and choices cannot be imposed upon the patient. The nurse must empower the patient to make her own decisions. Empowerment will help the patient develop strength to make growth-producing decisions independently. The remaining options would be counterproductive or have no bearing on the success of the care plan. DIF: Cognitive Level: Application REF: Page 532 TOP: Nursing Process: Planning

20. A patient who is a policewoman tells the nurse she is depressed and can no longer deal with the stress of her job. She mentions that employee assistance counseling failed to change her hopeless attitude. She states that she will use her police revolver to shoot herself in the head during the day when no one is at home and the home is locked. Which formulation by the triage nurse is correct? a. Plan explicit. Imminence high. Method highly lethal and accessible. Rescue potential low. b. Plan vague. Imminence moderate. Method somewhat lethal and accessible. Rescue potential moderate. c. Plan complete. Imminence low. Method low lethality but accessible. Rescue potential high. d. Plan nebulous. Imminence low. Method low lethality but accessible. Rescue potential high.

A The correct option identifies that the plan is well thought out; the imminence is high because the patient is ready to act; the gun is a highly lethal method, and she has the weapon; and the rescue potential is low because a gun is the chosen method. The remaining options do not show the proper assessment of these criteria. DIF: Cognitive Level: Analysis REF: Page 511 TOP: Nursing Process: Assessment

14. Which protocol should guide the nurse responsible for administering pharmacologic interventions for a patient who is experiencing alcohol intoxication? a. Medication interventions are based on the presence of withdrawal symptoms. b. Medications are prescribed at appropriate intervals for at least one full week. c. Symptoms are managed with medications for only the initial 24 hours of hospitalization. d. Medications are introduced to treat grand mal seizures that may accompany withdrawal symptoms.

A The course of intoxication is usually self-limiting to approximately 24 hours, after which withdrawal symptoms can occur for a time period unique to each patient. Treatment is directed by the symptoms the patient is experiencing, which generally emerge during the withdrawal stage. Seizures are among several serious symptoms that can occur during the withdrawal stage. DIF: Cognitive Level: Application REF: Page 350 TOP: Nursing Process: Implementation

: Basic Care and Comfort 29. A patient with bipolar disorder reveals to the clinic nurse that she may be 4 weeks pregnant. Which action will the nurse take? a. Confer with the physician about ordering a pregnancy test and discontinuing lithium. b. Educate the patient to the risk to the fetus as a result of exposure to the lithium in her blood. c. Suggest to the physician that the lithium dose should be increased for better symptom control. d. Remind the patient that barrier birth control methods should be used to prevent pregnancy during lithium therapy.

A The first need is to learn whether the patient is pregnant. Lithium ingestion by the mother can cause fetal damage. Lithium should be discontinued, not increased, if pregnancy is confirmed. It is premature to discuss fetal malformations before the pregnancy is confirmed. Options b and c are inappropriate and harmful. Birth control information has no value unless the pregnancy test is negative. DIF: Cognitive Level: Application REF: Page 250 TOP: Nursing Process: Implementation

4. Which group would be the target population for educational material on the dangers of binge drinking? a. Full-time college students b. Blue-collared young adults c. Older widows and widowers d. High school juniors and seniors

A The highest prevalence of binge and heavy drinking is among young adults between the ages of 18 and 25 years, with the majority being full-time college students. DIF: Cognitive Level: Application REF: Page 329 TOP: Nursing Process: Planning

8. A patient with chronic schizophrenia had a stroke involving the hippocampus. The patient will be discharged on low doses of haloperidol. The nurse will need to individualize the patients medication teaching by: a. Including the patients caregiver in the education b. Being careful to stress the importance of taking the medication as prescribed c. Providing the education at a time when the patient is emotionally calm and relaxed d. Encouraging the patient to crush or dissolve the medication to help with swallowing

A The hippocampus plays a major role in short-term memory and, hence, in learning. Taking the medication as prescribed and providing the education at a time when the patient is calm and relaxed is information or considerations that all patients should be given. The medication does not necessarily need to be crushed or dissolved since the stroke would not have caused difficulty with swallowing. DIF: Cognitive Level: Application REF: Page 102 TOP: Nursing Process: Planning

6. Which psychiatric nursing intervention shows an understanding of integrated care? a. A chronically abused woman is assessed for anxiety. b. A manic patient is taken to the gym to use the exercise equipment. c. The older adult diagnosed with depression is monitored for suicidal ideations. d. A teenager who refuses to obey the units rules is not allow to play video games.

A The majority of health disciplines now recognize that mental disorders and physical illnesses are closely linked. The presence of a mental disorder increases the risk for the development of physical illnesses and vice versa. Assessing a chronically abused individual for anxiety call should attention to the psychiatric disorder that could develop from the abuse. The remaining options show interventions that are appropriate for the mental disorder. DIF: Cognitive Level: Application REF: Page 6 TOP: Nursing Process: Implementation

21. The novice nurse is learning about the appropriate use of touch with patients experiencing psychiatric disorders. Which statement about touch will provide the nurse with the best basis for successful practice in psychiatric nursing situations? a. Touch carries a different meaning for different individuals. b. Touch is rarely misinterpreted by patients because of its universal appeal. c. It is seldom inadvisable to touch a patient to convey interest and warmth. d. Paranoid patients accept procedural touch best when combined with humor.

A The meaning of touch is highly individualized and is influenced by the length of the touch, the part of the body touched, the way the patient is touched, and the frequency of touch. Touch is often misinterpreted and not universally accepted. It may be highly inappropriate to use touch with certain patients to convey warmth and interest. Suspicious patients often do not have a sense of humor and regardless would likely find touch unacceptable. DIF: Cognitive Level: Application REF: Page 76 TOP: Nursing Process: Planning (Communication and Documentation)

: Reduction of Risk Potential 42. What milieu factor would need most attention from the nurse who is caring for a patient who has received six ECT treatments and has two more scheduled? a. Safety b. Trust attainment c. Therapeutic activities d. Boundary maintenance

A To feel safe, patients need to know what is expected of them in their role as patients. The patient receiving ECT often has impaired recent memory and may become confused about the milieu and expectations. The nurse will need to reorient and reteach the patient with cognitive deficit. Options b, c, and d will require attention but not to the same extent as safety. DIF: Cognitive Level: Analysis REF: Page 620 TOP: Nursing Process: Planning

3. To plan care for a patient with a psychiatric disorder, the nurse keeps in mind that the primary nursing role related to therapeutic activities is: a. Assisting the patient in accomplishing the activity b. Ensuring that the patient will comply with the rules of the activity c. Ensuring that the patient can accomplish the activity in a timely manner d. Providing a support system for the patient if they fail to complete the activity

A The nurses role in therapeutic activities is that of a professional observer and participant who works with the therapist to enhance the patients capabilities and functioning within the parameters of the assigned activity. Assuring accomplishment, compliance, or providing failure support are not nursing roles. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Planning

27. Prior to discharge, the nurse plans to teach the patient and family about relapse. Which items will the nurse include in the teaching? a. Recognizing warning signs of relapse b. Using street drugs judiciously and only in small amounts c. Lowering medication dosage to manage emerging side effects d. Notifying the nurse of warning signs present for more than one month

A The patient and family must be aware of signs of impending relapse. These signs are usually similar to those that the patient experienced prior to hospitalization and will be patient-specific. The nurse should be notified ASAP, rather than waiting two weeks. Patients should never adjust medication dosage. Street drug use often precipitates relapse since many street drugs are dopaminergic. DIF: Cognitive Level: Application REF: Page 277 TOP: Nursing Process: Implementation

7. Which outcome has priority for a patient with borderline personality disorder being discharged from an outpatient treatment environment? a. Patient demonstrates control over self-destructive impulses. b. Patient can identify symptoms that indicate a need for psychotherapy. c. Patient demonstrates an understanding of the importance of medication compliance. d. Patient actively participates in a community 12-step group related to relevant care.

A The patients ability to control self-destructive impulses has priority over the other options because doing so will affect patient safety. DIF: Cognitive Level: Analysis REF: Page 310 TOP: Nursing Process: Assessment

13. The nurse is planning care for a patient who was admitted to the hospital after threatening to harm himself when he was stopped by the police for speeding. He was intoxicated at the time of admission and was assessed as being depressed, anxious, and hostile. Which patient outcome is the priority? a. Patient will remain free from self-harm although hospitalized. b. Patient will report suicidal ideation or desire to harm self to the staff. c. Patient will accept referral to the hospital-based substance abuse program. d. Patient will recognize and interrupt unconscious intentions to harm self.

A The primary outcome is for the patient to be free from self-harm because the primary issue for this patient is the high risk for self-harm. The remaining options are all actions that will support this outcome. DIF: Cognitive Level: Application REF: Page 516 TOP: Nursing Process: Outcome Identification

37. Which of the following statements would correctly serve as a basis for teaching a family the usual outcome of an adjustment disorder? a. The symptoms will likely resolve completely. b. The patient may continue to be in danger of self-harm. c. Medications are frequently used to mask the symptoms. d. Relaxation is an effective tool to decrease and manage stress.

A The prognosis for most patients with adjustment disorders is good. In the majority of cases, identification of the stressor and use of effective coping strategies result in resolution. Continued self-harm is not a usual outcome for an adjustment disorder. Medications are not used routinely to treat adjustment disorders. Relaxation techniques are interventions rather than outcomes. DIF: Cognitive Level: Application REF: Page 238 TOP: Nursing Process: Implementation

29. The wife of a patient newly diagnosed with paranoid schizophrenia is concerned that her husband will be this sick for the rest of his life. What information can the nurse provide to the wife? a. This disorder generally responds well with treatment and follow-up. b. All types of schizophrenia by their nature are chronic relapsing disorders. c. Outcomes are related to the patients pre-hospital symptoms of disorganization. d. The typical outcome for this diagnosis is that total remission is not achievable.

A The prognosis for paranoid schizophrenia is good with appropriate treatment and effective follow-up. The remaining options are not correct when considering this type of schizophrenia DIF: Cognitive Level: Application REF: Page 274 TOP: Nursing Process: Implementation

14. A patient has been physically abused by her boyfriend frequently since moving in together. During her last discussion with the nurse, the patient stated, I probably should not keep going back to him, because he continues to abuse me. The nurse is aware that the final decision to leave a batterer is: a. Usually a gradual process that occurs over time b. Likely to occur after the victim suffers a serious injury c. More likely if the patient has approval from her family d. Made when the batterer gives her permission to do so

A The victim usually moves slowly when making the decision to leave the batterer because of many self-imposed constraints and many environmental factors that must be considered. It is unlikely that a batterer will give permission for the victim to leave. The remaining options are not supported by current research. DIF: Cognitive Level: Application REF: Page 533 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 28. A patient with schizophrenia is seen in the ED in an acutely agitated state resulting from threatening auditory hallucinations. The patients medical record indicates he has had severe dystonic reactions to parenteral administration of typical antipsychotic medication. The nurse can anticipate that the physician will order: a. Ziprasidone (Geodon) b. Fluphenazine (Prolixin) decanoate c. Clozapine (Clozaril) d. Paroxetine (Paxil)

A This atypical antipsychotic comes in an injectable form and is effective in controlling agitated and assaultive behaviors. Fluphenazine (Prolixin) decanoate is a typical antipsychotic. Clozapine (Clozaril) is used only for refractory schizophrenia. Paroxetine (Paxil) is an SSRI. DIF: Cognitive Level: Application REF: Page 575 TOP: Nursing Process: Planning

19. A patient is struggling to explore and solve a problem. The nurse determines that it would be therapeutic to offer alternatives. Which verbal introduction should the nurse incorporate in order to achieve this objective? a. Have you thought of b. You should c. Why dont you d. I think you need to

A This encourages the patient to consider alternatives without giving advice. The other options are preludes to giving advice, which is not considered therapeutic. DIF: Cognitive Level: Application REF: Page 74 TOP: Nursing Process: Planning (Communication and Documentation)

17. A nurse is considering the therapeutic value of touch when planning care for an anxious patient. What is the initial question the nurse should answer before initiating this technique? a. How comfortable am I with touching this patient? b. Will the patient find therapeutic touch supportive? c. Does research support the use of therapeutic touch? d. Has therapeutic touch proven to be therapeutic with anxious patients?

A Touch will only communicate warmth and thus be therapeutic if the nurse is comfortable with it. Although the other options are all appropriate, they do not have priority in this situation. DIF: Cognitive Level: Application REF: Page 76 TOP: Nursing Process: Planning (Communication and Documentation)

9. Which patient would the group co-leaders determine is demonstrating Yaloms therapeutic factor termed universality? a. Patient A, who states he realizes he is not the only person who has a problem with loneliness b. Patient B, who displays dysfunctional interaction patterns learned in his family of origin c. Patient C, who states he finally feels a strong sense of belonging d. Patient D, who openly expresses his anger about his work

A Universality is the factor that refers to understanding that one is not unique, that others share thoughts, reactions, and discomforts like your own. Dysfunctional interaction refers to corrective recapitulation of the family group. A strong sense of belonging provides an example of cohesiveness. Display of anger is an example of catharsis. DIF: Cognitive Level: Application REF: Page 610 TOP: Nursing Process: Evaluation

15. Which response by the nurse would best assist a patient in de-escalating aggressive behavior? a. Tell me whats going on. b. Why are you getting so upset? c. If you throw something, you will be restrained. d. Its time for group therapy. You can talk there.

A Using how, what, and when to gather information is a nonthreatening approach. It will promote patient verbalization and explanation of events without causing the patient to become defensive. Mentioning restraints sounds threatening even though it may be meant to remind the patient of limits. Whyquestions are demanding and threatening to patients. Sending the patient into group therapy sidesteps the problem. DIF: Cognitive Level: Application REF: Pages 292-293 TOP: Nursing Process: Implementation

33. After being raped, a woman was told by her aunt, Im not surprised that happened to you. You always dress to show off your figure. The victim states, I cant believe that people can think that way. The rape crisis nurse correctly hypothesizes that the patient is: a. Being revictimized by society b. Overly sensitive to others views c. Overreacting to not resisting more strongly d. Unaware of the normalcy of male sexual aggression

A Victim blaming is common following a rape. Instead of blaming the rapist, many individuals lack knowledge and empathy and revictimize the woman. Rape education programs can be helpful in changing attitudes. The other options are hypotheses that continue to place blame on the victim. DIF: Cognitive Level: Application REF: Page 546 TOP: Nursing Process: Assessment

17. A nurse planning teaching for a parent group concerned with preventing family violence can discuss the fact that exposure to violence in the media: a. Desensitizes people to the violence around them b. Has no effect on the increase of violence in society c. Broadens the viewers knowledge about world happenings d. Helps to distinguish appropriate behaviors from inappropriate behaviors

A Violence in the media has been shown to desensitize people to environmental violence. Desensitization to violence results in people being apathetic about the violence going on around them. The remaining options are not true statements. DIF: Cognitive Level: Application REF: Page 528 TOP: Nursing Process: Planning

33. When a father states, I dont understand what the doctor means by saying my daughter has an adjustment disorder. The nurse explains that this disorder often results from: a. Failure of existing coping skills b. Lack of stable emotional support c. Denial that a problem truly exists d. Overcompensation to present a controlled appearance

A When existing coping skills are not adequate to deal with a stressor, and new coping skills have not been developed, symptoms appear. These symptoms may fit the DSM-IV-TR criteria for adjustment disorder. The lack of emotional support is not applicable to the situation. The disorder does not result from use of denial since patients usually recognize that a problem exists. Overcompensation is not related to the onset of adjustment disorder. DIF: Cognitive Level: Application REF: Page 228 TOP: Nursing Process: Implementation

24. Which outcome would be appropriate for the detoxification phase of treatment for alcoholism? a. Adequate dietary protein intake b. Re-connection with family and support system c. Identification of triggers that cause alcohol abuse d. Control over emotions resulting in aggressive behavior

A When implementing any plan, patient safety and health are always the first priorities, so the nurse focuses on nutritional support, including providing a protein-rich diet. The remaining options are outcomes reserved for the later stages of the recovery process. DIF: Cognitive Level: Application REF: Page 349 TOP: Nursing Process: Planning

10. When facilitating change in the behavior of a patient diagnosed with a personality disorder, which intervention will have the greatest impact on success? a. Collaborating with the patient when establishing treatment goals b. Educating the patient to the importance of complying with treatment interventions c. Evaluating the patients understanding of the etiology of the prescribed medications d. Conducting regular assessments so the treatment can be changed when necessary

A When planning interventions with a patient who has a personality disorder, it is important to recognize that the person has disturbed values that do not reflect the views held by the general population. Because of these disturbances, the nurse needs to collaborate with the patient regarding the goals that are identified during treatment. The remaining options although appropriate will not be attainable if the patient does not recognize the interventions as being useful and personally applicable. DIF: Cognitive Level: Analysis REF: Page 312 TOP: Nursing Process: Implementation

36. The nurse has been working with a patient who has adjustment disorder with depressed mood. Which finding would permit the nurse to accurately evaluate that the crisis has been resolved? a. Absence of presenting symptoms b. Decreased need for medications c. Increased socialization with peers d. Significant increase in the patients appetite

A When the presenting symptoms are absent, the nurse can evaluate the problems as resolved. Most patients with adjustment disorders do not require medication, so this is not a good indicator. Data do not substantiate that the patient is experiencing problem socializing. This could indicate the patient is overeating as a means of dealing with stress. DIF: Cognitive Level: Application REF: Page 253 TOP: Nursing Process: Evaluation

23. The expert nurse is confident that the novice nurse understands the principles that guide the planning of patient care interventions when the: a. Novice nurse asks the patient to identify their primary concerns b. Patient successfully achieves the agreed upon nursing outcomes c. Expert nurse requests that the novice nurse observe several care planning sessions d. Novice nurse includes interventions that are supported by evidence-based practices

A Working with the patient to determine treatment priorities is a characteristic of good care planning. Although successful achievement of expected outcomes and inclusion of EBP interventions reflect appropriate care planning, such success is influenced by many different factors. Although appropriate, observing care planning sessions does not necessarily affect successful care planning on the part of the novice nurse. DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: Analysis

1. A patient is being evaluated for a possible diagnosis of panic disorder with agoraphobia. Which nursing assessment findings support this diagnosis? Select all that apply. a. Patient states, Ive had these fears for more than 6 years. b. Patient describes having a panic attack several times a month. c. Patient is embarrassed by the limitations the disorder causes. d. Stated, I never even think about going shopping in a crowded mall. e. Condition began after beginning treatment for a chronic intestinal problem.

A, B, C, D To meet the first DSM-IV-TR criterion for panic disorder with agoraphobia, the person must experience recurrent, unexpected panic attacks, with at least one attack followed by one of the following for a month: (1) persistent concern about having additional attacks; (2) worry about the implications of the panic attacks; or (3) a significant change in behavior as a result of the attacks. The second criterion is that the individual experiences agoraphobia. Agoraphobic fears typically involve being in a crowd. The third criterion is that the person avoids agoraphobic situations or has anxiety about having a panic attack. This person will not go to an area or event where he or she has experienced an agoraphobic reaction. The fourth criterion states that panic attacks are not caused by the direct effects of a substance, a medication, or a medical condition. DIF: Cognitive Level: Analysis REF: Page 195 TOP: Nursing Process: Assessment

3. The nurse is preparing a patient for a positron emission tomography (PET) scan. Which instructions will the nurse include? Select all that apply. a. There will likely be a 30 to 45 minute wait between the injection and the beginning of the scan. b. A blindfold and earplugs may be used to help decrease reaction to the environment during the scan. c. Make every attempt to lie still during the scan because movement will affect the imaging produced. d. No food or fluids are to be ingested for at least 8 full hours before the scan and none during the scan. e. Staying awake during the scan is important since the results are altered when the patient is in any phase of the sleep state.

A, B, C, E Appropriate patient preparation for a PET scan would include information regarding the time interval between injection of the isotope and the actual scan, the fact that steps will be taken to minimize the effects of sights and sounds during the scan, lying still is critical to achieving a quality image, and that being asleep during the scan will alter the results. It is not necessary to fast before or during the scan. DIF: Cognitive Level: Application REF: Page 110 TOP: Nursing Process: Implementation

2. When implementing Freuds theory of human psychosexual development, the nurse observes for behaviors that are characteristic of successful completion of stages that include (select all that apply): a. Anal, where self-confidence is formed b. Oral, where the ability to trust is developed c. Latency, where a person learns inner control d. Adjustment, where developmental failures are re-addressed e. Phallic, where the ability to interact with others is grounded

A, B, C, E Freuds stages of psychosexual development include in order of completion: oral, anal, phallic, latency, and genital. There is no adjustment stage in Freuds theory. DIF: Cognitive Level: Comprehension REF: Pages 302-303 TOP: Nursing Process: Assessment

5. A patient comes to the ED exhibiting severe physical and emotional symptomology. When no physical cause can be found for the symptoms, the patient is diagnosed with severe anxiety with panic attack symptoms. Which assessment data supports this diagnosis? Select all that apply. a. Blood pressure 158/90; 15 minutes later 130/80 b. Claims that she feels like she going to die c. Random but controlled thoughts d. Unable to follow instructions e. Dry, flushed skin

A, B, D Blood pressure will begin to drop in a panic attack as the sympathetic nervous system release occurs; the patient may express an emotional sensation of doom and the patient will not be able to concentrate and so will be unable to follow instructions. Thoughts during a panic attack are uncontrolled and the skin is diaphoretic. DIF: Cognitive Level: Analysis REF: Page 193 TOP: Nursing Process: Assessment

4. A patient with schizophrenia is described as having difficulty with executive functions. What patient dysfunction can the nurse expect to assess behaviorally? Select all that apply. a. Invades the personal space of others frequently b. Consistently fails to bring money when going to buy snacks c. Cannot remember the names of staff who often provide care d. Requires repeated reinforcement on how to make a sandwich e. Frequently speaks of hurting himself or of hurting other patients

A, B, D Executive functions include reasoning, planning, prioritizing, sequencing behavior, insight, flexibility, judgment, focusing on tasks, responding to social cues, and attending in appropriate ways to incoming stimuli. Memory is not considered an executive function and risk for harm to self and others is not generally a diagnosis appropriate for such a patient. DIF: Cognitive Level: Application REF: Page 100 TOP: Nursing Process: Assessment

2. Which statements regarding a hypomanic episode are true? Select all that apply. a. Behavior has been observed in the patient for at least 4 days. b. Patient appears unaware of potentially dangerous situations. c. Hospitalization is generally required to stabilize the behavior. d. Patient is engaging in behaviors that are normally uncharacteristic of them. e. Primary difference between mania and hypomania is the nature of the activity.

A, B, D Manic and hypomanic episodes share symptom criteria, and they differ primarily with regard to their severity and duration but not the nature of the activity. Hypomanic episodes are not severe enough to cause significant impairment in social and occupational functioning or to require hospitalization. However, for diagnosis, it must be evident that the mood and behavioral disturbances of hypomaniarepresent a definite change in the persons usual functioning that lasts for at least 4 days. As judgment declines, patients sometimes fail to recognize the consequences of their actions and the presence of possible danger. DIF: Cognitive Level: Application REF: Page 236 TOP: Nursing Process: Assessment

3. The nurse has been working for several weeks with a single mom who has been both verbally and physically abused by her childrens father. Which nursing actions are appropriate for this stage of treatment? Select all that apply. a. Asking, How does it make you feel when he hits you? b. Providing information regarding womens shelters in the local area c. Assuring the patient that her children can visit when she wants to see them d. Sharing that, I know leaving him is difficult but you need a plan if he abuses you again. e. Responding, Youve certainly become more assertive; dont be afraid to stand up for yourself.

A, B, D The working phase of the nurse-patient relationship involves evaluating the affects of the abuse, providing information that will help formulate a plan to end or manage the effects of the abuse, and encouraging the patient to confront the problem even when it is stressful. Assuring the patient that her children may visit is something that would happen in the orientation phase of the relationship when making the patient comfortable and responsive to treatment occurs. Positively reinforcing behaviors occurs in the termination phase as preparations are being made for discharge. DIF: Cognitive Level: Analysis REF: Pages 74-75 TOP: Nursing Process: Implementation (Communication and Documentation)

4. Which statement helps assure the nurse that the patient has an understanding of how their health information is managed to assure their right to confidentiality? Select all that apply. a. I had to sign a paper saying my information could be released. b. My records will be released to only people who really need to know. c. All the doctors will have access to my medical records when Im here. d. No one can see my information unless I say its okay for them to see it. e. My insurance company will get what they need in order to cover the bill.

A, B, D, E At the time of admission to a mental health facility, admission staff often request that patients sign a release-of-information document. The release of information usually includes the information that will be released; the persons or parties that the information will be shared with, such as other health care providers and insurance providers; the purpose of the release of the information; and the period of time during which the information will be released. Only the professionals who are involved with the care will have access to the patients medical records. DIF: Cognitive Level: Application REF: Page 171 TOP: Nursing Process: Evaluation

3. Which lifestyle changes should the nurse incorporate in the nursing care plan for a patient with generalized anxiety disorder? Select all that apply. a. Stop smoking. b. Limit caffeine intake. c. Eliminate stress from your life. d. Practice a relaxation technique daily. e. Limit worrying to specific times each day.

A, B, D, E CNS stimulants, including caffeine and nicotine, increase anxiety symptoms such as heart rate and muscle tension. Relaxation techniques are invaluable in the management of stress and anxiety. Limiting the time to allow worrying will help control the invasive thoughts. One cannot avoid stressful situations and attempting to do so does not help in managing its affects. DIF: Cognitive Level: Application REF: Page 200 TOP: Nursing Process: Planning

1. Which assessment findings suggest to the nurse that this patient has characteristics seen in an individual who has reached self-actualization? Select all that apply. a. Reports to have, found peace and security in my religious faith b. Effectively changed occupations when a chronic vision problem worsened c. Has consistently earned a six-figure salary as an architect for the last 10 years d. Has been in a supportive, loving relationship with the same individual for 15 years e. Provides free literacy tutoring help at the local homeless shelter 3 evenings a week

A, B, D, E Characteristics of self actualization would include: spiritual well-being, open and flexible, relationally fulfilled, and generosity toward others. Salary doesnt necessarily reflect self-actualization. DIF: Cognitive Level: Application REF: Page 4 TOP: Nursing Process: Assessment

5. Which nursing actions show a focus on the fundamental goals that guide psychiatric mental health nurses in providing patient care? Select all that apply. a. Offering an informational session of identifying signs of depression at a local senior center b. Attending a workshop on evidence practice interventions for the chronically depressed patient c. Keeping strict but appropriate boundaries with a patient diagnosed with a personality disorder d. Asking a parent who has just experienced the death of a child if they could consider talking with a grief counselor e. Identifying what help a patient diagnosed with Alzheimers disease will need with instrumental activities of daily living (IADLs)

A, B, D, E Standard objectives guide PMH nurses and members of related disciplines in the care of patients (individuals, families, communities, and organizations). The objectives and criteria are as follows: the promotion and protection of mental health, the prevention of mental disorders, the treatment of mental disorders, and recovery and rehabilitation. Keeping appropriate boundaries is a generalized nursing responsibility. DIF: Cognitive Level: Analysis REF: Page 3 TOP: Nursing Process: Implementation

2. Which interventions will the nurse implement to assure effective staff crises management skills? Select all that apply. a. Schedule regular staff crises simulations. b. Encourage the staff to discuss the details of unit crises. c. Attempt to identify staff who are ineffective during crises. d. Review documentation that describe the details of unit crises. e. Review unit crises management policies for needed updates.

A, B, D, E The correct options empower the staff while improving/maintaining their crises management skills. The failures of the process should be identified without blaming staff for ineffective crises management. DIF: Cognitive Level: Application REF: Page 293 TOP: Nursing Process: Planning

2. For which medication will the nurse prepare material for the family of a patient diagnosed with mild to moderate Alzheimers disease? (Select all that apply.) a. Tacrine (Cognex) b. Donepezil (Aricept) c. Haloperidol (Haldol) d. Rivastigmine (Exelon) e. Galantamine (Razadyne)

A, B, D, E The only drug that is not generally prescribed for Alzheimers disease is Haldol. DIF: Cognitive Level: Comprehension REF: Page 386 TOP: Nursing Process: Implementation

1. Which behaviors are reflective of legitimate phases of a groups development? Select all that apply. a. Stating the goals of the group b. Establishing who will assume the leadership role c. Inviting family members to attend and provide their input d. Feeling safe enough to discuss painful personal situations e. Showing concern about assuming personal responsibility for life

A, B, E All groups progress through the phases of development that are governed by group dynamics and include orientation where goals are identified, conflict where leadership is determined and tested, cohesion where a sense of safety is achieved, and termination where discharge concerns are acted out and addressed. Family input may not necessarily be introduced unless it was a defined goal of the group. DIF: Cognitive Level: Application REF: Pages 611-612 TOP: Nursing Process: Assessment

7. What actions by a nurse identify an understanding of the nursing responsibility to treat the patient with consideration to the ethical component of beneficence? Select all that apply. a. Frequently self-reflecting on whether the nursing interventions are actually helping the patient b. Evaluating whether the intervention is causing the patient unacceptable levels of anxiety or pain c. Recognizing that the moral rule of primum non nocere does not apply to the mentally ill patient d. Being willing to influence the patient in making decisions concerning the need for unpleasant treatments e. Consistently setting boundaries to effectively deflect a patients inappropriate sexually-oriented behaviors

A, B, E Individuals who work in the health care field have a special duty and responsibility to act in a manner that is going to benefit rather than harm patients. The term beneficence refers to bringing about good. Self-reflection concerning interventions and frequent evaluation of the effects of treatment on the patient is critical to beneficent care. Maintaining a therapeutic environment by providing an appropriate nurse-patient relationship is a vital component to fulfilling the obligation to act in a beneficent manner. The moral rule of primum non nocere (first do no harm) is vital in clinical interventions with persons with mental illnesses. The nurse should not influence patient decisions but rather provide information to support an educated decision whenever possible. DIF: Cognitive Level: Application REF: Page 182 TOP: Nursing Process: Evaluation

3. Privileged communication is a legal concept that in some states protects the confidentiality of the nurse-patient relationship. Which information is not protected by this statute? Select all that apply. a. A threat to kill that man if he even thinks about leaving me b. The patients admission to having a sexually transmitted disease c. The fact that a patient knows who was responsible for her brutal rape d. The discussion about how the patient sold his prescription drugs to friends e. Suspicion by the nurse that the patient has been physically abused by a spouse

A, B, E Privileged communication allows certain information given to professionals by patients to remain secret during any litigation. These statutes exclude the mandatory reporting of violence against a child, an older adult, an impaired adult, and (in some instances) a domestic partner; some communicable diseases that affect public safety; and information that will prevent a felony (e.g., murder) from occurring. Only the patient can give the information regarding her rape and the privilege prevents the nurse from sharing information such as illegal selling of drugs to be used against the patient in a court of law. DIF: Cognitive Level: Application REF: Page 171 TOP: Nursing Process: Implementation

1. Which interventions will the nurse implement to preserve milieu safety when a patient becomes agitated? Select all that apply. a. Project confidence and control. b. Provide a show of force when appropriate. c. Ask the agitated patient why they are feeling so aggressive. d. Move to within 5 feet of the patient to help contain their movement. e. Provide the patient with several options as means of de-escalating the crisis.

A, B, E The correct options demonstrate that the staff is in control without unnecessarily challenging the patient. Asking why is often interpreted as being challenging and often serves to future agitate the patient. Eight feet is considered to be the therapeutic distance between patient and staff in this type of situation. DIF: Cognitive Level: Application REF: Page 293 TOP: Nursing Process: Planning

2. Which nursing interventions are required by The Joint Commission (TJC) when the decision is made that a patient will benefit from the use of physical restraints? Select all that apply. a. The patients family is telephoned and told that restraints were applied. b. The restraints are removed when the patient agrees to cooperate with staff. c. A staff member is assigned to sit next to the patient until the restraints are removed d. The nurse provides the patient with a timetable that identifies when the restraints will be removed. e. The nurse notifies the patients mental health care provider that a face-to-face assessment is needed

A, C, D The Joint Commission (TJC) standards require that the patients family and legal representatives be notified when restraints are used, and the licensed independent practitioner (LIP) is required to assess the patient within 1 hour of the application of the restraints. The staff is also now required to perform continuous in-person observation of any patient in restraints for the duration of the restraint procedure. The criteria for removal of the restraints is not based exclusively on the patients stated willingness to cooperate or is the nurse required to provide the patient with a specific time when the restraints will be removed. DIF: Cognitive Level: Application REF: Page 173 TOP: Nursing Process: Implementation

4. The nurse shows an understanding of an essential purpose of therapeutic communication when (select all that apply): a. Asking the patient, How did it make you feel when your son died? b. Encouraging the patient to assume responsibility for the problems he or she has c. Attentively listening as the patient describes the reasons he or she is seeking help d. Providing the patient with feedback regarding how he or she is implementing stress relief techniques e. Sharing with the patient the details of several extremely stressful personal events and how they were managed

A, C, D Therapeutic communication has three essential purposes: (1) to allow the patient to express thoughts, feelings, behaviors, and life experiences in a meaningful way to promote healthy growth; (2) to understand the significance of the patients problems and the roles that the patient and the significant people in his or her life play in perpetuating those problems; and (3) to assist with the identification and resolution processes of the patients health-related behaviors. Encouraging the patient to assume responsibility for his or her problems may not be appropriate in all cases and it is not appropriate for the nurse to share personal information even if it relates to a problem similar to the patients. DIF: Cognitive Level: Analysis REF: Page 68 TOP: Nursing Process: Implementation (Communication and Documentation)

3. Which nursing actions indicate an understanding of the priority issues currently facing psychiatric mental health nursing today? Select all that apply. a. Working on the facilitys Safe Use of Restraints Policy revision committee b. Advocating for increased salaries for all levels of psychiatric mental health nurses c. Attending a political rally for increased state funding for mental health service providers d. Offering an in-service to facility staff regarding the cultural implications of caring for the Hispanic patient e. Joining the state nursing committee working on the role and scope of practice of the advanced practice psychiatric nurse

A, C, D, E Priority issues include funding, safety issues in psychiatric treatment centersparticularly the use of patient restraints, quality-of-care issues, access to health care for minority populations, and standardization of advanced practice nurse roles. DIF: Cognitive Level: Application REF: Page 9 TOP: Nursing Process: Implementation

6. Which actions show the nurse has an understanding of the role documentation plays in minimizing the risk of malpractice? Select all that apply. a. Including patient quotes to document subjective symptomology b. Supporting documentation with personal opinions of the patients behaviors c. Being mindful to use correct spelling and punctuation in the documentation d. Using common abbreviations in order to keep documentation brief and concise e. Documenting the nursing evaluation of the patients understanding of all instructions

A, C, E Adequate and legible documentation is the best means of defense against a lawsuit and the best way to validate that the nurse adhered to their scope of practice and to a safe standard of care. It is important to be specific and to document symptoms by writing in quotes how the patient expresses them. The reliability of the documentation is in question if spelling and punctuation is neglected. Documentation of all patient outcomes shows affective nursing care. Documentation should not include personal opinions or abbreviations not approved by the health care facility. DIF: Cognitive Level: Application REF: Page 179 TOP: Nursing Process: Implementation

5. A chronically depressed patient has been asked to participate in a research project focusing on effectiveness of alternative therapies. The nurse determines that the patient has an appropriate understanding of the guidelines that directs a research project when he states (select all that apply): a. I hope they find a treatment that doesnt involve drugs. b. I plan to use all the money I get to pay off some of my bills. c. Helping to find a treatment for depressed people is a good thing. d. My doctor told me that I had a responsibility to get involved in this. e. Im confident that this research project has very little risk involved.

A, C, E Guidelines for informed consent require that the patient understands the purpose of the research, any risks and possible discomforts to the subject, and possible benefits to the individual or to others. It is most important to note that the research is voluntary and that it clearly reflects autonomy on the participants part. Research subjects seldom receive payment for their involvement in the project. DIF: Cognitive Level: Application REF: Page 175 TOP: Nursing Process: Evaluation

2. The nurse has identified a nursing diagnosis of disturbed thought processes for a patient with obsessive-compulsive disorder. What abilities displayed by the patient would be related to an appropriate outcome for this problem? Select all that apply. a. Can identify when obsessions are worsening b. Speaks of obsessions as being embarrassing behaviors c. Describes lessening anxiety when compulsive rituals are interrupted d. Plans to ignore obsessive thoughts and so minimizes resulting stress e. Limits time focusing on obsessive thoughts to 15 minutes, 4 times a day

A, C, E It is desirable for the patient to experience a sense of being able to identify and control the obsessive thinking and the resulting anxiety. Identifying the behaviors as embarrassing is not showing control nor is ignoring the behaviors. DIF: Cognitive Level: Application REF: Page 200 TOP: Nursing Process: Evaluation

4. A teen says to the school nurse, Huffing is harmless. There are no reasons not to sniff inhalants. The nurse can reply knowing that (select all that apply): a. Such behavior can result in irreversible hearing impairment. b. There has been minimal research done on the effects in teens. c. Long-term use can result in poor short- and long-term memory. d. Irreversible kidney damage is often observed with even casual use. e. Research indicates both central nervous system and bone marrow damage.

A, C, E Research as shown that even teens who engage in sniffing high concentrations on inhalants often experience hearing loss, CNS and bone marrow damage, and impaired cognitive function. Kidney impairment is often seen as reversible. DIF: Cognitive Level: Application REF: Page 343 TOP: Nursing Process: Implementation

: Physiological Adaptation 5. The unit physicians have ordered magnetic resonance imaging (MRI) tests for the following patients. For which patients would the nurse decline to make test arrangements without further discussion with the physician? Select all that apply. a. A patient who is claustrophobic b. A patient who is breastfeeding c. A patient who has an allergy to iodine d. A patient who had a total knee replacement e. A patient who is taking a neuroleptic medication

A, D Patients with claustrophobia are often unable to complete this type of study, because the MRI machine is enclosed, and patients are required to remain motionless. Metal implants are contraindications for MRIs since metal affects the scan. Breastfeeding, iodine sensitivity, and neuroleptic medication therapy are not contraindications for an MRI. DIF: Cognitive Level: Application REF: Page 111 TOP: Nursing Process: Assessment

1. When assessing a patient diagnosed with a mood disorder, which abnormal diagnostic tests would be considered a possible factor in the manifestation of the disorder? Select all that apply a. RBC (red blood cell) b. ECG (electrocardiogram) c. BUN ( blood urea nitrogen) d. TSH (thyroid stimulating hormone) e. Blood glucose

A, D, E Anemia, hyper- or hyperthyroidism, and diabetes mellitus are all medical conditions that can occur simultaneously with mood disorders. There is no research to support a strong connection between renal or cardiac disorders with mood disorders. DIF: Cognitive Level: Analysis REF: Page 236 TOP: Nursing Process: Assessment

5. What statements indicate that the patient has an understanding of assertive behavior? Select all that apply. a. Always stand up for your own rights. b. I say what it takes to make my wishes known. c. Talking really loud seems to get the focus on me. d. Im not uncomfortable telling someone No when I need to. e. You dont have to ignore the rights of others to stand up for yourself.

A, D, E The assertive person defends their personal rights while respecting the rights of others and is not uncomfortable saying no when they are feeling oppressed. The remaining options are more characteristic of aggressive behavior. DIF: Cognitive Level: Application REF: Page 71 TOP: Nursing Process: Evaluation (Communication and Documentation)

3. When suspicious of possible fetal alcohol syndrome, which assessment findings would support this diagnosis? Select all that apply. a. Webbed toes b. An enlarged head c. Super sensitive hearing d. A flattened bridge of the nose e. Symptoms of a septal heart defect

A, D, E The correct options are characteristics of FAS but one would not include hearing loss or a small head in children with this disorder. DIF: Cognitive Level: Application REF: Page 331 TOP: Nursing Process: Assessment

19. While planning care for a preschool child who has been physically and sexually abused, the nurse includes play therapy because it assists the child to: a. Learn adaptive behaviors through acting. b. Express feelings that cannot easily be verbalized. c. Act out aggression in a sociably acceptable manner. d. Interact with other children in the appropriate age group.

B Abused children, especially young children, are unable to put feelings into words as they describe events. Play therapy affords the tools through which the child can access and work through feelings. The other options are not purposes of play therapy. DIF: Cognitive Level: Application REF: Page 541 TOP: Nursing Process: Planning

13. The nurse notes that a patient being treated for an anxiety disorder is becoming more anxious sitting in a congested, noisy room waiting to see the therapist. Which intervention will the nurse implement initially to assist the patient in de-escalating his anxiety? a. Offering to reschedule the patients appointment b. Taking the patient to an unoccupied interview room c. Notifying the therapist of the need to see the patient stat d. Requesting oral prn anxiolytic medication for the patient

B A congested, noisy environment is not conducive to maintenance of low anxiety. Moving the patient to a less stimulating environment may be all that is needed for the patient to lower his anxiety level. The other options may not be necessary if the nurse intervenes effectively. DIF: Cognitive Level: Application REF: Page 201 TOP: Nursing Process: Implementation

24. In planning aftercare for a patient with schizophrenia and whose insurance benefits have been exhausted, the nurse who is concerned about overcoming negative symptoms will make provisions for the patient to have stimulation, structure, socialization, and support. Which option would best incorporate these factors? a. Day hospitalization b. Attending a psychosocial club c. Living with his elderly mother d. Spending free time in the mall

B A psychosocial club is organized to provide the 4 Ss and is not costly to patients. Day hospitalization would not be possible because of the lack of insurance benefits. Living with his mother might fall short of stimulation and support. Spending time in the mall lacks structure, socialization, and support. DIF: Cognitive Level: Application REF: Page 291 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 22. A patients serum lithium level is reported as 1.9 mEq/L. The nurse should immediately: a. Restrict sodium and fluid intake. b. Assess for signs and symptoms of toxicity. c. Seek to have the patient transferred to ICU. d. Notify the patients physician immediately.

B A serum lithium level this high suggests that the patient may be experiencing symptoms of lithium toxicity. Clinical assessment is essential to determine what, if any, signs and symptoms are present. After the clinical assessment has been made, the nurse can provide the physician with a complete picture. Restricting sodium and fluids would raise the serum level. Transferring may not be necessary and would require a physicians order. DIF: Cognitive Level: Application REF: Page 583 TOP: Nursing Process: Implementation

2. A patient has experienced a stroke (cerebral vascular accident) that has resulted in damage to the Broca area. Which evaluation does the nurse conduct to reinforce this diagnosis? a. Observing the patient pick up a spoon b. Asking the patient to recite the alphabet c. Monitoring the patients blood pressure d. Comparing the patients grip strength in both hands

B Accidents or strokes that damage Brocas area may result in the inability to speak (i.e., motor aphasia). Fine motor skills, blood pressure control, and muscle strength are not controlled by the Broca area of the left frontal lobe. DIF: Cognitive Level: Application REF: Page 100 TOP: Nursing Process: Implementation

39. The major rationale for careful ongoing assessment of a patient with adjustment disorder is: a. Characteristic symptoms abate but take at least 6 months to do so. b. The disorder may be a precursor to a more serious mental health problem. c. Practitioners become less discerning as they become more familiar with the patient. d. Patients with adjustment disorders have a high risk for self-harm, especially suicide.

B Adjustment disorders usually improve with identification of the stressor and development of coping strategies to relieve stress. If symptoms worsen, new treatment strategies must be developed to treat the more serious mental health disorder that has become apparent. There is no research to support the remaining options. DIF: Cognitive Level: Application REF: Page 238 TOP: Nursing Process: Implementation

21. A patient with dementia is unable to name ordinary objects. Instead, he describes the function of each item (e.g., the thing you cut meat with). The nurse assesses this as: a. Apraxia b. Agnosia c. Aphasia d. Amnesia

B Agnosia is the failure to identify objects despite intact sensory function. Apraxia is the inability to carry out purposeful, complex movements and use objects properly. Aphasia refers to inability to speak (expressive) or inability to comprehend what is said or written (receptive). Amnesia is inability to remember a significant block of information. DIF: Cognitive Level: Comprehension REF: Page 373 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 25. A patient who began haloperidol (Haldol) therapy 24 hours ago tells the nurse that he feels jittery and unable to sit or stand still. The nurse can hypothesize that this report is related to: a. Dystonia b. Akathisia c. Serotonin syndrome d. Neuroleptic malignant syndrome

B Akathisia, an extrapyramidal side effect, is characterized by restlessness, inability to sit still, and the need to pace. It usually occurs early in the course of treatment with a typical antipsychotic drug. The symptomology is not related or seen in the other options. DIF: Cognitive Level: Analysis REF: Page 570 TOP: Nursing Process: Assessment

3. What is the basis for assessing a male patient who is agoraphobic for panic attacks? a. Men are more likely to experience panic attacks. b. An overwhelming number of agoraphobic patients also have panic attacks. c. Patients are often unaware that the symptoms they are experiencing are those of panic. d. Panic attacks are generally the cause of a patient developing phobias like agoraphobia.

B Almost all patients who present with agoraphobia in clinical samples have a current diagnosis or history of panic disorder. Males are not more likely than females to experience panic attacks. Patients are not usually unaware of panic attack symptoms. Panic attacks dont cause, but are often triggered by, phobias. DIF: Cognitive Level: Application REF: Page 193 TOP: Nursing Process: Assessment

5. A patient who has schizoaffective disorder is being treated with lithium carbonate. He repeatedly resists his medication based on his fine hand tremors as proof of drug poisoning. Which nursing intervention addresses both the patients need to comply with treatment and patient rights? a. Informing staff that the patient is exhibiting manipulative behavior b. Providing the patient with effective education regarding medication side effects c. Assuring the patient the tremors are a result of the disorder, not of the medication d. Providing an assessment to determine if the patient is exhibiting paranoia as well

B Although the patient has a legal right to refuse medication, medication compliance is vital to successful treatment. Patient and family medication education by nurses and a reassuring therapeutic relationship will greatly assist with medication adherence while preserving the patients rights. Identifying manipulative behavior or paranoia does not address compliance or patient rights. The assurance about the tremors is not true. DIF: Cognitive Level: Analysis REF: Page 174 TOP: Nursing Process: Implementation

1. The nurse learns at report that a newly admitted manic patient is demonstrating grandiosity. Which statement would be most consistent with this symptom? a. I cant do anything anymore. b. Im the worlds most astute financier. c. I can understand why my wife is upset that I overspend. d. I cant understand where all the money in our family goes.

B An individual who is demonstrating grandiosity has an exaggerated view of his abilities. The other options are more moderate statements and lack that element of exaggeration. DIF: Cognitive Level: Application REF: Page 233 | Page 235 TOP: Nursing Process: Assessment

1. Which suicide is an example of Durkheims anomic suicide? a. A Muslim who was disgraced by a family member b. A woman whose life savings were embezzled from her c. A suicide bomber who blows up a bus in the middle East d. A convicted rapist who has been given a life sentence

B Anomic suicides are acts of self-destruction by individuals who have become alienated from important relationships in their groups, especially as this relates to their standard of living. Durkheim characterized egoistic suicides as the self-inflicted deaths of individuals who turn against their own conscience. Altruistic suicides are self-inflicted deaths on the basis of obedience to a groups goals rather than reflecting the persons own best interests. Durkheim defined fatalistic suicides as self-inflicted deaths that result from excessive regulation. DIF: Cognitive Level: Application REF: Page 503 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 14. What information concerning amitriptyline (Elavil) 50 mg tid would the nurse give the patient regarding the expected outcome of this medication therapy? a. Complying with this therapy will cure your depression. b. This medication is expected to improve brain chemical imbalance. c. Amitriptyline will help re-establish your ability to think clearly again. d. Elavil will be particularly effective at assisting you in regaining your independence.

B Antidepressant medication works by re-establishing the balance of neurotransmitters in the brain, particularly serotonin and norepinephrine. Antidepressants do not promise a cure for depression. Cognitive therapy, rather than antidepressants, addresses thinking issues. Learned helplessness is addressed by cognitive therapy. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Implementation

17. An elderly patient with dementia has a nursing diagnosis of self-care deficit: bathing, hygiene. She lives alone and the nursing assessment proves reason to believe she has forgotten how to perform hygiene and bathing activities. Which intervention is most appropriate for this patient? a. Bathe daily with reminders. b. Bathe twice weekly with assistance. c. Patient will be provided with in-home nursing care. d. Patient will be transferred to an assisted living facility.

B Bathing twice weekly would be a realistic goal. Assistance should be provided, both to prevent falls and to regulate shower temperature. The elderly are advised not to bathe daily because it is too drying to their skin. The remaining options are not supported by the information given in the scenario. DIF: Cognitive Level: Application REF: Page 383 TOP: Nursing Process: Outcome Identification

15. A patient has been chronically battered by her husband since they were married. Until now she had avoided dealing with her situation, but she now expresses a desire to deal with the problem since the attacks are occurring more frequently. Which outcome is realistic for the patient? a. Setting a goal date for divorcing her husband b. Verbalizing an awareness of her increasingly dangerous situation c. Citing possible ways she may have contributed to the abusive episodes d. Employing methods of retaliating in order to gain experience being assertive

B Because the abuse has been long-term and is increasing in intensity, the patient needs to state her awareness of being in danger. When the patient accepts this fact, she may be increasingly ready to make further plans to extricate herself. The victim is not at fault for abuse. Setting a divorce date is not practical because she has not begun to pursue litigation. Retaliation is not an effective means of resolving the problem. DIF: Cognitive Level: Application REF: Page 532 TOP: Nursing Process: Outcome Identification

4. A patient has been admitted with a diagnosis of atypical depression. In planning interventions, the nurse would expect to consider the characteristic symptom of: a. Seasonal episodes b. Leaden paralysis c. Psychomotor agitation d. Increased depression in the morning

B Behavioral characteristics of atypical depression include the feeling that ones limbs are so heavy they cannot be lifted or moved (leaden paralysis). Seasonal mood changes are characteristic of seasonal affective disorder. Psychomotor agitation and depression that is greater in the morning than in the evening are characteristics more likely to be observed in patients with melancholic depression. DIF: Cognitive Level: Application REF: Page 237 TOP: Nursing Process: Planning

5. Which action will best facilitate the development of trust between a nurse and patient? a. Responding positively to the patients demands b. Following through with whatever was promised c. Clarifying with the patient whenever there is doubt d. Staying available to the patient for the entire shift

B Being consistent in keeping ones word implies that the nurse is trustworthy and does what is agreed upon. Being responsive to demands may not be therapeutic. Instead, the patient will need to learn new techniques for meeting needs. Clarification is important but is not the best method for promoting trust. Trust is better served by shorter contacts at agreed-upon intervals. DIF: Cognitive Level: Application REF: Page 603 TOP: Nursing Process: Implementation

32. A patient with schizophrenia tells the nurse as they sit in the day room, I hear voices telling me bad things. The most therapeutic response the nurse can make is: a. Tell me what the voices are saying. b. I believe you hear voices, but I dont hear them myself. c. The voices are not real. Theyre a product of your imagination. d. Do you think the voices would go away if we went into your room to talk?

B By voicing his or her own reality related to the voices, the nurse does not deny the patients experiences but helps the patient distinguish actual voices from those resulting from internal stimulation. Discussing what the voices are saying serves only to validate the reality of the voices. Challenging the voices will cause the patient to defend his perceptions and thereby reinforce the importance of the hallucination. Asking to move validates the reality of the voices and is not a helpful action since the voices go where the patient goes. DIF: Cognitive Level: Application REF: Page 277 |Page 283 TOP: Nursing Process: Implementation

18. Which situation would be most likely to serve as a trigger to a catastrophic reaction in a patient with stage 2 Alzheimers disease? a. Participating in singing Happy Birthday to another patient at dinner b. Being scolded by an aide for spilling a glass of milk c. Listening to Big Band music from the 1940s d. Eating cupcakes in the activities room

B Catastrophic reactions are overexaggerated negative emotional responses initiated as a result of a perceived failure at a task or change in the environment. Being scolded by the aide presents a situation that would clearly be frustrating to the patient. DIF: Cognitive Level: Application REF: Page 376 TOP: Nursing Process: Assessment

32. When a patient asks the nurse, How can jolting me with an electrical shock possibly do me any good? the answer most reflective of current biologic theory would be: a. ECT must sound like a very frightening treatment alternative to you. b. ECT produces a change in brain chemistry that results in improved mood. c. ECT interrupts brain impulses that are causing hallucinations and delusions. d. ECT provides you with external punishment so you can stop punishing yourself.

B Current theory regarding use of ECT is that the electrical stimulus causes electrochemical changes within the brain, resulting in increased availability of neurotransmitters at the synapses and improvement of mood. To suggest that the treatment is frightening does not answer the patients question. The treatment is not appropriate for hallucinations or delusions. The remaining option is not appropriate or founded in psychiatric therapy. DIF: Cognitive Level: Application REF: Page 618 TOP: Nursing Process: Implementation

16. By the end of the orientation phase, which outcome can be identified for a newly admitted patient? The patient will demonstrate: a. Ability to problem solve one issue b. Trust in at least one nurse on the unit c. Positive transference with a staff member d. Ability to ask for help in meeting needs

B Establishing trust in the nurse is a fundamental task of the orientation phase of the relationship; thus it is an appropriate outcome to identify. When trust is present, the patient is free to focus on the work and tasks of therapy. The ability to problem solve is an outcome appropriate for the working phase. Positive transference would not be an identified outcome. The ability to ask for help would not be an identified outcome for the orientation phase. DIF: Cognitive Level: Application REF: Page 611 TOP: Nursing Process: Outcome Identification

: Therapeutic Communication 10. A nurse best shows an understanding of the role of evidence-based research in achieving therapeutic patient care outcomes when: a. Subscribing to and reading a monthly psychiatric research nursing journal b. Working on a committee to revise current facility policies regarding the use of chemical restraints c. Registering to attend a psychiatric workshop on newly developed psychotropic medication therapies d. Asking an experienced staff member to review the interventions being proposed for a newly admitted patient

B Evidence-based practice is based on evidence and scientific principles that have been developed through research. The more closely clinical practice reflects relevant research, the more likely it is that patients will receive the best available care. The option that infers action directed at implementing the research is the one that shows best understanding. Reliance only on experience is not reflective of quality nursing care. DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: Planning

13. The wife of a patient with paranoid schizophrenia tells the nurse, Ive learned that my husband has several close relatives with the same disorder. Does this problem run in families? The response based on recent discoveries in the field of genetics would be: a. Your children should be monitored closely for the disorder. b. Research tends to support a familiar tendency to schizophrenia. c. There is no concrete evidence; it is just as likely a coincidence. d. Only bipolar disorder has been identified to have a genetic component.

B Familial tendencies appear with several psychiatric disorders including schizophrenia. To insinuate that the children are at such risk would not be supported by research. DIF: Cognitive Level: Application REF: Page 108 TOP: Nursing Process: Implementation

9. The nurse caring for a school-age child who has been sexually abused by a close family member demonstrates an understanding of communication barriers in this situation by: a. Realizing that repeated questioning by others will occur b. Assuring the child that the story they are telling is believed c. Reinforcing that the child will not be in trouble with the police d. Promising to tell only those who need to know about the incident

B Fear of being blamed or of being disbelieved is a powerful motivator of silence. When the child fears that there will be no support, there is no reason to disclose the abuse. The other options are much more remote. DIF: Cognitive Level: Analysis REF: Page 541 TOP: Nursing Process: Implementation

10. The nurse working at the crisis center received a call from a patient who stated he was depressed and wanted to die. Further investigation revealed that the patient had within reach all of the items listed below that he could use to get the job done. Which item would cause the nurse the most concern? a. A garden hose b. A loaded gun c. Two bottles of Prozac d. A bottle of an alcoholic beverage

B Firearms are the most lethal form of weapons that are used to complete suicide, with 50.2% of all individuals who completed suicide in 2007 doing so with a firearm. Using a firearm is a more lethal method of suicide than are medications, a garden hose, or a bottle of alcohol. It does not allow time for rescue. DIF: Cognitive Level: Application REF: Page 502 TOP: Nursing Process: Assessment

26. Which symptom related to thought-flow disturbance is the nurse most likely to assess in a newly admitted patient who is diagnosed with bipolar disorder, manic episode? a. Slow, halting speech b. Flight of ideas c. Schemata d. Anhedonia

B Flight of ideas is a continuous rapid flow of speech marked by jumping from topic to topic. It is a manifestation of thought disorder associated with inability to filter stimuli causing increased distractibility. Slow speech would be seen in depression. Neither schemata or anhedonia are symptoms of a thought-flow disorder. DIF: Cognitive Level: Application REF: Page 233 TOP: Nursing Process: Assessment

19. A patient with a borderline personality disorder tells the nurse, My doctor tells me theres something wrong with the hard wiring of my brain, and thats why Im so impulsive and get so many mood swings. He said hes going to prescribe some medication. Being aware of current practice guidelines, the nurse will prepare a teaching plan for: a. Lithium (Lithobid) b. Fluoxetine (Prozac) c. Lorazepam (Ativan) d. Haloperidol (Haldol)

B Fluoxetine is an SSRI. SSRIs are the medications of choice for patients with personality disorder who have affect dysregulation and impulsivity. SSRIs have a low incidence of side effects. Lithium may be used in instances of severe mood disorder. Lorazepam is used to help manage high anxiety, while haloperidol is prescribed in cases of violent behavior. DIF: Cognitive Level: Application REF: Page 315 TOP: Nursing Process: Planning

9. The physician tells the nurse, The medication Im prescribing for the patient enhances the g-aminobutyric acid (GABA) system. Which patient behavior will provide evidence that the medication therapy is successful? a. The patient is actively involved in playing cards with other patients. b. The patient reports that, I dont feel as anxious as I did a couple of days ago. c. The patient reports that both auditory and visual hallucinations have decreased. d. The patient says that, I am much happier than before I came to the hospital.

B GABA is the principle inhibitory neurotransmitter. The medication should provide an antianxiety effect. Alertness, psychotic behaviors, and mood elevation are not generally affected by g-aminobutyric acid. DIF: Cognitive Level: Application REF: Page 105 TOP: Nursing Process: Evaluation

24. Which intervention will provide the most information regarding a patients self-perception of their role in their environment? a. Asking the patient to keep a journal about things they enjoy doing b. Observing the patient interact with family members at a unit picnic c. Encouraging the patient to discuss the successes they have experienced d. Helping the patient select appropriate, attractive clothing for family visitation day

B How the patient interacts within the family system and the role that the patient takes (e.g., victim, placater) will offer the nurse the most insight into the patients self-perception. The other options are focused on assessing and/or affecting self-esteem. DIF: Cognitive Level: Application REF: Page 313 TOP: Nursing Process: Assessment

: Reduction of Risk Potential 39. About an hour after the patient has ECT, he complains of having a headache. The nurse should: a. Notify the physician stat. b. Administer an as needed (prn) dose of acetaminophen. c. Take the patient through a progressive relaxation sequence. d. Advise going to activities to expend energy and relieve tension.

B Post-ECT headache is common. Most physicians routinely write an as needed (prn) order for a headache remedy. Notifying the physician is unnecessary, because this is an expected side effect. Options c and d would not be as useful as medication in this instance. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 13. A patient prescribed alprazolam (Xanax) for symptoms of anxiety shares with the nurse that, Im concerned about getting off this medication. Upon which fact will the nurse base the response to the patients concern? a. Long elimination half-life will result in a manageable withdrawal treatment plan. b. Rapid absorption and distribution to brain cells make withdrawal more difficult to manage. c. Sensitivity of the mesencephalic reticular activating system makes addiction unlikely. d. The combination of medication with an antidepressant often positively impacts withdrawal.

B In general, shorter-acting benzodiazepines are more difficult to taper and potentially cause more problems with withdrawal. The remaining options are neither true nor relevant. DIF: Cognitive Level: Application REF: Page 587 TOP: Nursing Process: Planning

13. The daughter of an elderly patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of stealing her money. The nurse assesses the patients stage of Alzheimers disease as stage: a. 1 b. 2 c. 3 d. 4

B In stage 2, memory and cognitive deficits are worsening. The patient is less able to make sense of a confusing world and makes faulty interpretations resulting in paranoid delusional thinking. The patient in stage 1 does not usually have delusions. The patient in stage 3 often is unable to communicate meaningfully. There is no stage 4 of Alzheimers disease. DIF: Cognitive Level: Comprehension REF: Page 375 TOP: Nursing Process: Assessment

: Reduction of Risk Potential 40. For which patient is the nurse most likely to need to schedule a pre-ECT workup and teaching? a. Patient A, who is newly diagnosed with dysthymic disorder b. Patient B, who has melancholic depression that responded well to ECT 2 years ago c. Patient C, who was unresponsive to a 6-week trial of SSRI antidepressant therapy d. Patient D, who has depression associated with diagnosis of inoperable brain tumor

B Indications for ECT include patients with major mood disorders; patients who have responded to ECT in the past; patients who are unresponsive to antidepressants or unable to tolerate their side effects; and patients who are acutely suicidal or in danger of fluid and electrolyte imbalance related to inability to eat due to depression, severe mania, or severe catatonia. Patients with dysthymia are not candidates for ECT. The patient has not run out of medication options when prescribed only an SSRI. Patients with space-occupying lesions of the brain are not candidates for ECT. DIF: Cognitive Level: Application REF: Page 618 TOP: Nursing Process: Planning

23. A woman whose husband physically abuses her mentions to the nurse, Someday Ill have to leave him. Which of the following would be the nurses best response? a. Yes, you should, before he harms you badly. b. Could we talk about developing a safety plan? c. Are you afraid of what your family will say? d. I dont know why you would stay with him.

B It is well known that the woman is at high risk for being killed or seriously injured when she leaves the abuser. Having a safety plan lowers the risk and makes leaving a less nebulous idea. The patient must make up her own mind. Asking about the familys response sidesteps the issue of safety. The patient needs empowerment, not criticism. DIF: Cognitive Level: Application REF: Page 532 TOP: Nursing Process: Implementation

7. What reason does the nurse give the patient for the emphasis and attention being paid to the recovery phase of their treatment plan? a. Recovery care, even when intensive, is less expensive than acute psychiatric care. b. Effective recovery care is likely to result in fewer relapses and subsequent hospitalizations. c. Planning for recovery care is time consuming and involves dealing with many complicated details. d. Recovery care is usually done on an outpatient basis and so is generally better accepted by patients.

B Much attention is paid to recovery care since effective recovery care helps improve patient outcomes and thus minimize subsequent hospitalizations. Recovery care is not necessarily less expensive than acute care. Although effective recovery care planning may be time consuming and detail oriented, that is not the reason for implementing it. Recovery care is not necessarily well accepted by patients. DIF: Cognitive Level: Application REF: Page 7 TOP: Nursing Process: Implementation

17. A patient who has a nursing diagnosis of ineffective coping related to ineffective problem solving has been involved in treatment for 6 months. The nurse determines that the planned interventions require revision when the patient states: a. I really dont think my psychiatrist actually helps me. b. I cant decide if I should get my own apartment or not. c. I cant accept that I will never be able to comfortably make decisions. d. I dont think Im liked well enough to seek election as a committee chairperson.

B Nursing interventions describe a specific course of action or a therapeutic activity that helps the patient to move toward a more functional state; in this case problem solving. The statement indicates indecision and suggests that problem solving is still a patient problem. Showing dislike of the physician actually shows a decision. Not accepting the realization of ineffective decision making is not related to ineffective coping but rather shows focus on affecting the problem. Expressing the perception that one is not liked concerns self-esteem. DIF: Cognitive Level: Application REF: Page 54 TOP: Nursing Process: Evaluation

8. Which sociological aspect, vital to relapse prevention, is greatly affected when a patient is found to have a dual diagnosis of psychosis and alcoholism? a. Ability to afford the cost of outpatient services b. A supportive, reliable, accessible support system c. Protection from both physical and emotional abuse d. Access to reasonable housing and employment opportunities

B Often individuals with this type of diagnosis have lost their support systems as a result of chronic mistreatment of their family and friends and an inability to maintain and recognize the importance of this aspect to their treatment plan. Although the remaining options impact relapse prevention, they are generally available when the patient is being supported appropriately. DIF: Cognitive Level: Application REF: Pages 335-336 TOP: Nursing Process: Planning

19. Which observation best supports the patients success with achieving long-term sobriety? a. Asking a family member to, get rid of all the alcohol before I come home b. Identifying all the problems alcoholism has caused the family over the years c. Being able to discuss the importance of attending a support group for alcoholics d. Promising to, stop the drinking so I can be a good parent and raise a good child

B One of the most prominent factors that leads an individual to recovery is the patients recognition that substance use has caused or influenced his or her lifes problems and interrupted his or her functioning. The remaining options lack that element of self-reflection. DIF: Cognitive Level: Application REF: Pages 344-345 TOP: Nursing Process: Assessment

25. A patient with catatonic schizophrenia has been standing with his left arm upraised and his right foot off the floor for the majority of the last 20 hours, eating only when allowed to eat standing up. Which nursing intervention has priority for this patient? a. Providing high-calorie drinks hourly b. Assessing for lower extremity edema bid c. Taking the patient to activities therapy once daily d. Encouraging the patient to sit or lie down for 30 minutes hourly

B Patients who maintain one position for long periods of time should be assessed for dependent edema. In this case, the nurse would look for edema of the lower extremities and would be concerned about the pressure exerted by standing on one foot for long periods of time. Such encouragement would probably be met with resistance by the patient. High-calorie drinks would be necessary if the patient failed to eat at meals. The patient probably would not be able to cognitively process what is required to participate in activities. DIF: Cognitive Level: Application REF: Page 275 TOP: Nursing Process: Implementation

: Basic Care and Comfort 26. Which nursing action best addresses the needs of a paranoid patient who believes the food is poisoned? a. Explaining that others eat the food and are not harmed b. Allowing the patient to select food from vending machines c. Encouraging the patient to discuss why someone would poison the food d. Taking steps to prevent the patient from verbalizing the delusional thoughts

B Patients who think hospital food is being poisoned will sometimes eat wrapped foods that have not been opened, and occasionally, they may eat food brought from the outside by a trusted person. Delusions are fixed, false beliefs that cannot be refuted by logic. The patient will probably state that the others have been given the antidote to the poison. Encouraging discussion about the delusion is not therapeutic. Although it is wise to minimize the amount of discussion about delusions, refusing to allow the patient to speak about the delusions will not foster a therapeutic alliance. DIF: Cognitive Level: Application REF: Page 273 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 15. Which principle should the nurse apply when planning nursing care for a patient who was voluntarily admitted after a suicide attempt? a. Patients who attempt suicide and fail will not try again. b. The more specific the plan, the greater the risk for suicide. c. Patients who talk about suicide are less likely to attempt it. d. Patients who attempt suicide and fail do not really want to die.

B Patients whose suicidal ideation includes a vague, diffuse plan or no plan at all are not at as high a risk for attempting suicide as an individual who has a well-developed plan and the means to carry it out. The nurse will need to continually reassess the patient. None of the remaining options are true statements concerning suicide attempts. DIF: Cognitive Level: Application REF: Page 244 TOP: Nursing Process: Planning

6. A 27-year-old woman diagnosed with borderline personality disorder displays a labile affect, impulsivity, frequent angry outbursts, and difficulty tolerating her angry feelings without self-injury. A priority nursing diagnosis for this patient is: a. Anxiety b. Risk for self-mutilation c. Risk for other-directed violence d. Ineffective coping

B Patients with borderline personality disorder frequently engage in self-mutilation in an attempt to manage chaotic feelings. The important clue to this diagnosis is that the patient is having difficulty tolerating feelings without self-injuring. There is no data to support anxiety or ineffective coping. The risk is greater for violence toward self. DIF: Cognitive Level: Application REF: Page 306 TOP: Nursing Process: Diagnosis

28. Because of the cognitive disturbances associated with schizophrenia, which technique will be useful as the nurse teaches a patient about self-management? a. Use only verbal instruction. b. Teach material in small segments. c. Offer opportunities for making numerous choices. d. Plan the teaching for a time when the patient has been recently medicated.

B Patients with cognitive disturbances should be taught small blocks of information at a time and given frequent reinforcement. Both verbal and visual materials should be used since processing of verbal stimuli may be more impaired. Teaching should be scheduled when the patient is most alert. A large number of choices may be confusing for the person, but a few simple choices may be included. DIF: Cognitive Level: Application REF: Page 279 TOP: Nursing Process: Implementation

23. Which behavior is of particular concern to the nurse when managing the care of a patient diagnosed with a personality disorder? a. Reporting a staff member for wanting to hurt me b. Shoplifting two candy bars from the hospitals gift shop c. Asking much more frequently to be allowed to smoke a cigarette d. Refusing for three days to either bathe or change into clean clothing

B Patients with personality disorders often exhibit self-destructive behaviors that result in getting themselves in trouble with the law, such as shoplifting. The remaining options are not generally considered characteristic behaviors of the patient diagnosed with a personality disorder. DIF: Cognitive Level: Application REF: Page 318 TOP: Nursing Process: Assessment

21. Which statement correctly describes the schizotypal personality disorder? a. Psychotic behavior will require a long hospitalization. b. There may be misinterpretation of events but not psychosis. c. There is greater personality disorganization than in schizophrenia. d. The patient will be outgoing, actively seeking interactions with others.

B Patients with schizotypal personality disorder may have problems thinking and accurately perceiving events, but symptoms of psychosis such as delusional thinking and hallucinations will be absent. Personality disorganization is greater in schizophrenia. Psychosis will require longer hospitalization. Patients with schizotypal personality disorder are not generally outgoing and social. DIF: Cognitive Level: Application REF: Page 306 TOP: Nursing Process: Assessment

2. A child was admitted to the childrens unit, having been sexually abused by an acquaintance of her family. The child refuses to talk and participate in unit activities, choosing to stay in her room with her stuffed animals. Which therapeutic intervention will best help the child release pent-up feelings about the abuse? a. Family therapy b. Play therapy c. Individual communication with the nurse d. Role-play with other children on the unit

B Play helps communicate and release feelings about the childs problems. A child may have difficulty expressing feelings verbally. Family therapy may be useful, but it is not designed for releasing feelings. Role-playing is more effective with older children or adults. DIF: Cognitive Level: Application REF: Page 541 TOP: Nursing Process: Implementation

; Psychological Integrity 16. The nurse responsible for the care plan of a patient diagnosed with cognitive impairment includes rationales for the nursing interventions primarily to: a. Provide a means for outcome evaluation b. Account for the reasoning that drives the nursing action c. Support the patients success in achieving the expected outcome d. Provide information to aide in the implementation of the nursing action

B Rationales primarily reflect nurses accountability for their actions by explaining why the action is necessary and expected to positively impact the patients condition. Rationales are not used to support or evaluate the success of the intervention nor to educate how the action should be preformed. DIF: Cognitive Level: Application REF: Page 56 TOP: Nursing Process: Planning

9. The nurse working with patients diagnosed with posttraumatic stress disorder (PTSD) is aware of the need to intervene early in order to de-escalate a patients increasing anxiety level. Which patient behavior is likely an early indication of escalating anxiety? a. Talking rapidly b. Pacing around the unit c. Staring out the window d. Refusing to go to therapy

B Recognize the patients use of relief behaviors (e.g., pacing, wringing of hands) as indicators of anxiety. Talking rapidly is an indicator of manic behavior. Staring is more likely seen in depression. Refusing to attend therapy is seen in aggressive, defiant patients. DIF: Cognitive Level: Application REF: Page 200 TOP: Nursing Process: Assessment

25. A patient is scheduled to attend an occupational therapy group to work on the identified goal of recognizing and using more effective coping techniques. What measure can the nurse use to continue to support the patients attainment of this goal after he returns to the unit? a. Isolating him from more seriously ill patients b. Praising him for positive behavioral changes c. Avoiding setting limits that would increase his anxiety level d. Permitting him to make mistakes prior to intervening on his behalf

B Recognizing and pointing out positive changes provides encouragement to continue pursuing change. The remaining option would not achieve the nurses goal of supporting the patients use of effective coping techniques. DIF: Cognitive Level: Application REF: Page 617 TOP: Nursing Process: Implementation

22. A suicidal patient agreed on day 2 of hospitalization to write and sign a no self-harm contract. As a result of this contract, the health care team should plan to: a. Discontinue suicide precautions. b. Base the level of observation on staff assessment. c. Reduce observation to observing the patient every hour. d. Reduce one-to-one observation to observing the patient every 15 minutes.

B Research suggests that no-harm contracts may not prevent self-harm; therefore any reduction in suicide precautions is incorrect. Staff assessment needs to be continued and based on observation. DIF: Cognitive Level: Application REF: Page 518 TOP: Nursing Process: Implementation

20. A nurse is contemplating the use of self-disclosure. The expected outcome of this strategy is that the patient will: a. be informed about expected behaviors b. express previously withheld feelings c. foster a mutually supportive relationship with the nurse d. recognize that the nurse can empathize through shared experiences

B Self-disclosure should serve one or more of the following purposes: to model and educate; to build the therapeutic alliance; to provide concrete reflection that encourages reality testing. The nurse does not use self-disclosure foster a interdependent relationship that in any way gives support to the nurse. Empathy does not rely upon shared experiences. DIF: Cognitive Level: Application REF: Page 76 TOP: Nursing Process: Planning (Communication and Documentation)

15. The expected outcome of conducting a periodic self-evaluation of ones own responses to patients is for the nurse to continue: a. Recognizing the nurses need for therapy b. Recognizing personal problems and strengths c. Maintaining distance from the patients problems d. Maintaining professional boundaries with the patients

B Self-evaluation of responses to patients will reveal whether the nurse is responding with objectivity versus subjectivity, acceptance or rejection, calmly or with anger, and with sympathy or anxiety. The goal is not identify the nurses need for therapy or to maintain distance for patient problems, but rather to remain objective about them. The purpose of a self-evaluation is to recognize the nurses responses, not to maintain boundaries. DIF: Cognitive Level: Application REF: Pages 68-69 TOP: Nursing Process: Assessment

3. The nurse is leading a support group for women who have experienced interpersonal violence. When a patient asks about the characteristics of the perpetrators of interpersonal violence, the nurse accurately responds that they are: a. Usually under the influence of alcohol b. Most often someone the victim knows c. A stranger to the victim in most cases d. Often in a psychotic state during the act

B Statistics show that interpersonal violence is usually committed by someone the victim knows. Drugs and alcohol are not necessarily involved. The victim usually knows the perpetrator. The perpetrators are aware of what they are doing. DIF: Cognitive Level: Application REF: Page 526 TOP: Nursing Process: Assessment

1. An advanced practice nurse evaluates a patient for emergency commitment because of the likelihood the patient will do serious harm to others. Which statement best reflects the nurses role as patient advocate during the assessment process? a. Tell me about any delusions you are experiencing. b. I understand you have had some difficulty today. c. Tell me why you need to threaten or hurt others around you. d. Threatening to hurt others will require that you be committed to the hospital.

B The advocacy role of nurses to help patients to obtain, maintain, and fully make use of mental health benefits is critical. Assessment for commitment requires data collection from the patient. This statement is the most neutral of the options given and the most open ended; therefore it will be most likely to elicit a response. It is an unfounded assumption that the patient is delusional. Why questions will usually elicit rationalizations from the patient. Making a statement about the resulting hospitalization is not information gathering. DIF: Cognitive Level: Application REF: Page 169 TOP: Nursing Process: Implementation

3. The nurse is explaining the advantage of advanced directives to a patient diagnosed with schizophrenia. Which psychiatric outcome is a result of such preplanning? a. Allows healthcare providers to manage the patients mental health care b. Decreases the possibility that the patient will be committed involuntarily c. Directly impacts the type of care the patient will receive as the disease progresses d. Assures that the patient will retain continued autonomy and independence of living

B The implementation of psychiatric advance directives significantly decreases involuntary commitments. Healthcare management and treatments are not affected by psychiatric advanced directives. The patients continued autonomy and independence is more related to the condition not the directives. DIF: Cognitive Level: Application REF: Page 170 TOP: Nursing Process: Implementation

26. A suicidal patient tells the nurse, Theres no other way out for me. I have so many problems that theres nothing to do but cash it in. Which statement by the nurse would be a helpful approach? a. I can see that things are bad. Its good you recognized your limitations. b. Lets look at the problem you consider most urgent to see about a solution. c. Well begin problem-solving together as soon as you stop feeling suicidal. d. Your thinking is flawed. Ill teach you to think differently and be less depressed.

B The most effective intervention is to help the patient prioritize problems and work on them one at a time. To affirm the negative is not therapeutic. Although a change in thinking is appropriate, it does not deal with the patients statement about problems. The remaining option places unrealistic demands on the patient. DIF: Cognitive Level: Application REF: Page 517 TOP: Nursing Process: Implementation

13. Which intervention will best ensure a nonjudgmental evaluation of a patients noncompliance with the treatment plan for management of his antisocial behaviors? a. Re-evaluating the patients understanding of the goals of the prescribed treatment plan b. Asking questions that focus on his perception of why he can follow his treatment plan c. Expressing concern about the patients long-term prognosis if his noncompliance continues d. Re-assessing the patient for changes that may require the revision of his current treatment plan

B The nurse asking questions to determine possible reasons for the outcome criteria not being met would exhibit a nonjudgmental approach to this patients assessment interview. While appropriate, the remaining options are not nonjudgmental in nature. DIF: Cognitive Level: Analysis REF: Page 315 TOP: Nursing Process: Implementation

10. A 19-year-old patient is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The patient sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the patients condition as: a. Social isolation b. Disturbed thinking c. Altered mood states d. Poor impulse control

B The nurse interprets the patients statements that were not reality-based as indicating disturbed thought processes. Social isolation is not the primary patient problem. No data exist to support the other options. DIF: Cognitive Level: Application REF: Pages 278-279 TOP: Nursing Process: Diagnosis

22. What is the primary reason for the nurse to have an understanding of the various types of activity and adjunct therapies? a. The nurse chooses the most cost-effective therapy group. b. The nurse is expected to encourage patients involvement in the therapies. c. The nurse is responsible for placing the patient in the appropriate group. d. The nurse needs to be supportive of the treatment team members who direct these therapies.

B The nurse must interpret to patients and others that the purpose of activity therapies is to increase patient awareness of feelings and behaviors and to minimize pathology and promote mental health. Although they are important, supportiveness, encouragement, and economics are not the primary reason. DIF: Cognitive Level: Analysis REF: Page 618 TOP: Nursing Process: Planning

23. A patient with melancholic depression paces and wrings her hands for hours at a time while repeating, Im a bad person. Staff members have been unsuccessful in their attempts to promote rest. Which intervention is most appropriate in promoting rest? a. Instructing the patient to lie down for 15 minutes of every hour b. Asking the patient to fold and stack bath towels and washcloths c. Making the patient aware of the negative effects of fatigue on mood d. Reassuring the patient that she is accepted and not considered a bad person

B The psychomotor energy of agitation must be expended; it may be channeled into simple, repetitive activity. Standing in one place to fold towels is an improvement over pacing. This patient will be unable to comply with the request to lie down. A severely depressed patient will not be able to cognitively process this sort of information. Reassurance will not appreciably affect the need for psychomotor activity. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Implementation

15. A patient diagnosed with delirium has become agitated and fearful. Which nursing intervention should the nurse implement to help prevent a catastrophic response? a. Interact with the patient on an adult-to-child level. b. Place the patient in a safe, nonstimulating environment. c. Ask the patient to explain what is causing the agitation and fear. d. Be prepared to apply physical restraints to minimize the patients risk for injury.

B The safety of a patient with delirium is of primary importance. Symptoms of delirium fluctuate and may worsen, especially at night. The greater the patients confusion and disorientation, the greater the possibility for self-harm. The patient should be treated as an adult; to do otherwise is demeaning. Asking for an explanation is inappropriate, because delirious patients cannot formulate rational answers. Patients are never restrained unless all other less restrictive measures have failed. DIF: Cognitive Level: Application REF: Page 376 |Page 383 TOP: Nursing Process: Implementation

: Physiological Adaptation 19. The wife of a patient diagnosed with paranoid schizophrenia asks, Ive been told that my husbands illness is probably related to imbalanced brain chemicals. Can you be more specific? The response based on the dopamine hypothesis is: a. Breakdown of dopamine produces LSD, which in large amounts produces psychosis. b. An increase in the brain chemical dopamine explains the presence of delusions and hallucinations. c. Decreased amounts of the brain chemical dopamine explain the presence of delusions and hallucinations. d. An increase in the brain chemical dopamine explains the presence of lack of motivation and disordered affect.

B The statement is correctly based on the dopamine hypotheses while the remaining options are neither known to be true nor based on that theory DIF: Cognitive Level: Comprehension REF: Page 266 TOP: Nursing Process: Implementation

26. A teenager is admitted to the ED after being alternately hyperalert and difficult to arouse. The symptoms started within the last few hours, during which time he became disoriented, confused, and delusional. These symptoms support the diagnosis of: a. Amnesia b. Delirium c. Dementia d. Depression

B The symptoms are indicative of delirium. The other options are not supported by the scenario. DIF: Cognitive Level: Application REF: Pages 371-372 TOP: Nursing Process: Assessment

6. The nurse presenting a suicide prevention lecture would decide who the target population is based on what fact? a. Females have the highest risk for suicide. b. Children are considered a high-risk group for committing suicide. c. The highest suicide rate is among the Caucasian middle-age population. d. Rates of suicide are highest among the older population, age 80 and older.

D The highest rate of suicide is among the older adult population. The remaining options are not true statements. DIF: Cognitive Level: Application REF: Page 502 TOP: Nursing Process: Planning

13. A nurse has for the past 4 weeks been working with a psychotic patient who has been mute and very withdrawn. The patient suddenly encroaches on the nurses personal space by touching inappropriately. What is the most therapeutic response by the nurse to address this behavior? a. Ignore it this time because the patient is, at last, responding. b. Firmly communicate acceptable boundaries to the patient. c. Gently touch the patients head and then observe the reaction. d. Smile while telling the patient that people dont like being touched like that.

B The therapeutic response is to clearly communicate appropriate boundaries. There are times when patients misinterpret the nurses nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. The behavior should not be ignored since doing so may well result in the patient repeating the behavior with others, perhaps with disastrous results. Touch is often misinterpreted by psychotic patients and in this case has no therapeutic value. Nonverbal communication should always be congruent so as to avoid confusing the patient. DIF: Cognitive Level: Application REF: Page 75 TOP: Nursing Process: Implementation (Communication and Documentation)

7. A patient diagnosed with Alzheimers disease has a catastrophic reaction during an activity involving simultaneous playing of music and working on a craft project. The patient starts shouting no, no, no and rushes out of the room. The nurse should: a. Discontinue the activity program since it upsets the patients. b. Follow the patient, reassure her, and redirect her to a quieter activity. c. Isolate the patient until she is calm, and then direct her back to the activity. d. Give the patient prn antianxiety medication and restrict her activity participation.

B These actions will restore safety and self-esteem. Isolation will decrease self-esteem and may increase confusion. It is only one patient that is distressed, not the entire group. Behavioral interventions should be attempted prior to administering medication. DIF: Cognitive Level: Application REF: Page 376 TOP: Nursing Process: Implementation

8. Which behaviors would indicate that a therapeutic activity program for a patient with Alzheimers disease had been successful? a. Accurate recent memory, positive emotional response, and increased verbal expression b. Increased attention span, verbal expression of remote memory, and positive emotional response c. Positive use of perseveration, reduction in use of habitual skills, and improved abstract reasoning d. Positive emotional response, ability to remember multiple steps, and accurate recent memory

B These are all observations that would indicate that a therapeutic activity program has kept the patient functioning at the highest level of which he is capable. The behaviors described in the other options are not realistic expectations for this patient. DIF: Cognitive Level: Application REF: Page 387 TOP: Nursing Process: Evaluation

9. The nurse has developed a plan in which nursing interventions are used to reinforce the patients healthy behaviors. Which statement by the nurse will positively reinforce the patients efforts regarding the plan? a. How can a stress reduction plan help you at home? b. It sounds like you have the incentive to make healthy choices. c. When you tried to follow the plan, how well did it work for you? d. It sounds as though making healthy choices is very important to you.

B This answer offers a positive response to a patient who is trying out new behaviors. This nursing response will serve to encourage the patients efforts. The remaining options do not provide positive reinforcement but rather are attempts to gather more information or clarify the patients motivation to change. DIF: Cognitive Level: Application REF: Page 75 TOP: Nursing Process: Implementation; Health Promotion and Maintenance (Communication and Documentation)

18. The nurse mentions, I like to use open-ended questions and statements because they result in fuller, more revealing responses by the patient, and they stimulate discussion. What statement would the nurse ask to best stimulate conversation with a patient about their family? a. Where does your family live? b. Tell me about your family. c. Do you have a family nearby? d. Would you like to talk about your family?

B This broad opening will encourage discussion as well as allow the patient to decide what to include about his or her family. The remaining options can all be answered with a yes or no response and so do not stimulate communication. DIF: Cognitive Level: Application REF: Page 72 TOP: Nursing Process: Planning (Communication and Documentation)

24. The nurse is planning care for a battered woman who has mentioned, Someday Ill have to leave him. Which outcome should the nurse include in the plan of care for this patient? a. Patient will leave husband for a safe environment within 3 weeks. b. Patient will verbalize awareness of the dangerousness of her situation. c. Patient will state that she feels strong enough to return to the situation. d. Patient will state that she feels more relaxed after consultation with nurse.

B This is a realistic outcome for a patient who is beginning to consider leaving the abusive situation. Setting a timeline is premature. Feeling relaxed is more related to a problem of anxiety than to abuse. Returning is not an outcome that is in the patients best interest. DIF: Cognitive Level: Application REF: Page 532 TOP: Nursing Process: Outcome Identification

24. What measure will facilitate communication with a patient who is depressed and evidencing psychomotor retardation and withdrawal? a. Ask the patient to indicate yes or no with finger signals. b. Arrange to spend time with the patient at prearranged intervals. c. Give concrete and concise directions rather than asking questions. d. Speak loudly and rapidly to the patient to focus his or her attention.

B This measure will promote the establishment of rapport and demonstrate respect and acceptance of the patient. It will facilitate patient willingness to communicate thoughts and feelings without making unnecessary demands on the patient; a headshake or nod would work as well. Patients should not simply be ordered about; they should be asked to respond without placing excessive demands. Patients with psychomotor retardation have the ability to hear, but their ability to process information may be slowed, requiring well-paced simple communication. DIF: Cognitive Level: Application REF: Page 244 TOP: Nursing Process: Implementation

19. A patient has been displaying advanced thought of suicide. Which action reflects this behavior? a. Acknowledging thoughts of dying b. Expresses verbal expressions of severe sadness c. Wrists are bleeding from cuts with a butter knife d. Found unconscious with empty pills bottles nearby

C A nonlethal suicide gesture is characteristic of this degree of suicide risk. Having suicidal thoughts only is reflective of ideations although a verbal expression is a moderate risk gesture. An actual attempt that was potentially lethal is the ultimate risk behavior. DIF: Cognitive Level: Application REF: Page 512 TOP: Nursing Process: Assessment

4. Which of the following should the nurse use as a basis for explaining the etiology of Alzheimers disease to the family of a patient with this disease? a. It is a secondary dementia indicated by loss of recent memory and disorientation to time and place. b. It is a primary dementia that is incurable, irreversible, and fatal. It is caused by the presence of a beta-amyloid protein in the neurons resulting in senile plaques. c. It is a secondary dementia that is treatable with analysis of the diet and removal of toxic substances from the diet and environment. d. It is a primary dementia characterized by stepwise decreases in cognitive abilities. It is irreversible but treatable with antihypertensive medications.

B This option provides accurate information about Alzheimers disease. Alzheimers disease is not a secondary dementia nor is it treated with antihypertensive medications. DIF: Cognitive Level: Application REF: Pages 367-368 TOP: Nursing Process: Implementation

5. Which outcome is realistic for a patient with stage 1 Alzheimers disease? a. Caregiver will assume role of decision maker for patient to reduce stress. b. The patient will maintain the highest possible functional level to preserve autonomy. c. Arrangements will be made for appropriate long-term placement to minimize risk of injury. d. The patient will retain full physical functioning through cognitive and occupational therapies.

B This outcome addresses health maintenance (i.e., maintaining an optimal functional level as determined by present capacity). Although long-term placement may be an option, it is not necessarily appropriate during this stage. Patients in stage 1 are often able to make simple decisions. Continuing to make decisions gives the patient a sense of control. Although a patient in stage 1 does not appear markedly deteriorated, some diminution of function may be present. DIF: Cognitive Level: Application REF: Page 382 TOP: Nursing Process: Outcome Identification

1. The patient asks the nurse, Ive heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process? The response that explains the need for nurses to understand and use the nursing process is: a. Do you think you have a better method we might use? b. The nursing process is a systematic problem-solving method encompassing all components necessary to care for patients. c. Using the nursing process is a way of legitimizing our profession and placing us on an equal footing with the pure sciences. d. The nursing process is a unidimensional, static, linear approach used to guide nurses as they make clinical judgments.

B This response best explains the importance of the nursing process by description and relationship to patient care. Suggesting that the patient may have a better method is challenging and does not address the question posed by the patient. Providing legitimacy to the profession is a very limited explanation for use of the nursing process. The nursing process is not one-dimensional, static, or linear. DIF: Cognitive Level: Knowledge REF: Page 40 TOP: Nursing Process: Implementation

12. A patient has been admitted with disorganized type schizophrenia. The nurse asks the patient how he is feeling, and he responds, Everybody picks on me. They frobitz me. The best response for the nurse to make would be: a. Thats really too bad that you are being treated that way. b. Who do you mean when you say everybody? c. What difference does frobitzing make? d. Why do they frobitz?

B This response will help clarify the patients thinking and change the focus from global to specific. In this situation, sympathizing with the patient is a nonproductive response. The remaining options appear to accept the neologism thus supporting the patients delusional thinking. DIF: Cognitive Level: Application REF: Page 286 TOP: Nursing Process: Implementation

6. Which statement best defines the nurses initial role as the patients source of help in addressing interpersonal problems? a. Ill work with your doctor to help you get better. b. Ill be working with you to help solve your marital troubles. c. Your medications will help you feel better as soon as they take effect. d. You will be expected to attend the group activities while you are here.

B This statement clearly specifies the nurses purpose as a helping professional, and establishes the relationship as therapeutic, rather than social. The nurse has independent functions and does not work exclusively with the doctor. Identifying only medication overlooks the contributions of staff and the therapeutic milieu. Giving information is appropriate, but this statement does not define the nurses role as resource. DIF: Cognitive Level: Application REF: Page 604 TOP: Nursing Process: Evaluation

: Pharmacological and Parenteral Therapies 6. When asked how tricyclic antidepressants affect neurotransmitter activity, the nurse should respond that they: a. Decrease available dopamine. b. Increase availability of norepinephrine and serotonin. c. Make available increased amounts of monoamine oxidase. d. Increase the effects of the chemical gamma-aminobutyric acid.

B Tricyclic antidepressants block neurotransmitter uptake, increasing the amounts of norepinephrine and serotonin available. Decreasing dopamine is the action of typical antipsychotic medication. Increasing monoamine oxidase is not the action of tricyclics. Benzodiazepines, not tricyclics, increase the effects of GABA. DIF: Cognitive Level: Application REF: Page 578 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 23. To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in: a. Affective mobility b. Positive symptoms c. Self-care activities d. Cognitive functioning

B Typical antipsychotic medications produce improvement in the positive symptoms of schizophrenia such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement. DIF: Cognitive Level: Application REF: Pages 568-569 TOP: Nursing Process: Evaluation

1. A young child is being evaluated in the Emergency Department for injuries her mother reports resulted from a fall down the stairs. Which of these findings indicates that physical abuse may be a chronic problem for the child? a. The mothers description of the child as being clumsy b. Several fractures revealed on x-ray in varying degrees of healing c. Clinging to her mother as she attempted to leave the examining room d. Struggling with the staff when attempts to obtain a blood specimen were made

B Unhealed fractures indicate both numerous injuries and that medical intervention was not sought at the time of injury. Although unkind, the mothers description of the child is not reason to believe chronic abuse has occurred. The remaining options reflect normal behavior, especially if pain or separation is suspected. DIF: Cognitive Level: Application REF: Page 539 TOP: Nursing Process: Assessment

21. A college student diagnosed with high levels of anxiety is being prepared for discharge. Which discharge criteria is appropriate for this patient? a. The patient will avoid situations that cause anxiety. b. The patient will use learned anxiety-reducing strategies. c. The patient will return to living at home with supportive parents. d. The patient will state, I know medication is what I need to control my anxiety.

B Using anxiety-reduction strategies will promote maximal functioning. Trying to avoid stressful situations is impractical and encourages avoidance, therefore limiting activities and not supporting the development of coping mechanisms. Moving back into the parents home promotes dependency, and medication therapy is not necessarily the only treatment for anxiety. DIF: Cognitive Level: Application REF: Page 198 TOP: Nursing Process: Planning

16. An appropriate nursing strategy to assist a patient who was involuntarily admitted after a suicide attempt is:: a. Avoiding any focus on the topic of suicide b. Encouraging patient to verbalize personal feelings c. Supporting patient focus on others rather than self d. Discussing the impact of suicidal thoughts on the family

B Verbalization helps relieve pent-up feelings and emotional pain. Avoidance of the topic is nontherapeutic for a suicidal patient. The remaining options may serve to increase the patients feelings of guilt. DIF: Cognitive Level: Application REF: Page 244 TOP: Nursing Process: Implementation

24. A patient with moderate dementia does not remember her sons name. The son repeatedly questions the mother asking, Do you know my name? The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son: a. Your mother is angry with you and is punishing you by forgetting who you are. Be patient and shell get over it. b. Your mothers dementia is preventing her from retaining information even for short periods of time. She senses your distress and becomes agitated. c. You will need to reorient your mother often during your visits with her. With reinforcement, she may be able to begin to recall who you are. d. Because you both become so distressed, it might be better if you come to see your mother less frequently and stay for only shorter periods of time.

B When a patient with dementia is presented with a demand that exceeds their capacity to function, the demand creates a high level of stress. Showing anxiety and disapproval adds even greater stress. The son should be counseled to make every attempt to demonstrate positive responses to his mother. The other options are not effective interventions. DIF: Cognitive Level: Application REF: Page 383 TOP: Nursing Process: Implementation

6. Which considerations should a nurse include when conducting a mental health assessment on a culturally diverse patient Select all that apply. a. Men and women are equally likely to seek psychiatric health care. b. The role that spirits and magic play in a patients belief system is cultural based. c. Rituals are only deemed obsessive when applied to the patients cultural standards. d. Agoraphobia is more difficult to assess in cultures that restrict female socialization. e. The nurse should consider the universal application of the Diagnostic and Statistical Manual (DSM-IVTR).

B, C, D Some cultures restrict womens participation in public activities; thus agoraphobia is less commonly diagnosed. Fears of magic and spirits are present in many cultures and are pathologic only when they are deemed excessive in the context of that culture. Many cultures have rituals to mark important events in peoples lives. The observation of these rituals is not indicative of OCD unless it exceeds norms for that culture, is exhibited at times or places that are inappropriate for that culture, or interferes with social functioning. Most research that supports the development of the Diagnostic and Statistical Manual, ed 4, text revision (DSM-IVTR) classification occurred in the United States; consequently,symptoms that define disorders are representative of U.S. culture. Overall, women are more likely than men to present for treatment or to come in contact with health care providers. DIF: Cognitive Level: Application REF: Page 193 TOP: Nursing Process: Planning

2. A nurse engaged in primary prevention for substance abuse among adolescents could advise parents to (select all that apply): a. Watch for signs of depression. b. Help the teen anticipate pressures. c. Be a role model for effective coping skills. d. Support the teens interest in hobbies and sports. e. Require academic tutoring when grades begin to drop.

B, C, D The correct options are proactive and focus on preventing the problem although the remaining options intervene once there are indications that the problem may exist. DIF: Cognitive Level: Application REF: Page 334 TOP: Nursing Process: Implementation

2. A patient has begun experiencing dysfunction of the hypothalamus. What nursing interventions will the nurse include in the patients plan of care? Select all that apply. a. Reinforcing clear physical boundaries b. Assisting the patient with completing daily menus c. Learning about healthy sleep hygiene habits d. Monitoring and recording temperature every 4 hours e. Monitoring and recording blood pressure every 4 hours

B, C, D The hypothalamus is responsible for regulation of sleep-rest patterns, body temperature, and physical drives of hunger. Social appropriateness and blood pressure is not controlled by the hypothalamus. DIF: Cognitive Level: Analysis REF: Page 102 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 3. A patient taking fluphenazine (Prolixin) complains of dry mouth and blurred vision. What would the nurse assess as the likely cause of these symptoms? a. Decreased dopamine at receptor sites b. Blockade of histamine c. Cholinergic blockade d. Adrenergic blocking

C Fluphenazine administration produces blockade of cholinergic receptors giving rise to anticholinergic effects, such as dry mouth, blurred vision, and constipation. DIF: Cognitive Level: Application REF: Page 566 TOP: Nursing Process: Assessment

6. The nurse is working on the inclusion of therapeutic humor in interactions with a chronically ill schizophrenic patient who was hospitalized after an attempted suicide. Which outcomes are realistic expectations for this patient? Select all that apply. a. Improved cognition b. Decreased interest in self-harm c. Increased ability to experience pleasure d. Decrease in the expression of fear and anxiety e. Appropriate expression of emotions through affect

B, C, D, E In two studies, researchers found that humor-based group activities provided to patients with chronic schizophrenia showed that they had a significant reduction in negative symptoms, self-injury, self-reported anger, anxiety, and depression. Although the results may be preliminary, they suggest that humor-based interventions may be beneficial for patients with chronic mental illness. There is no supporting evidence that cognitive abilities improve with the introduction of therapeutic humor. DIF: Cognitive Level: Application REF: Page 77 TOP: Nursing Process: Planning (Communication and Documentation)

1. Which behaviors would demonstrate a strong possibility for successful rehabilitation for a patient with a substance abuserelated diagnosis? Select all that apply. a. States that, I promise Ill never use drugs again. b. Has shown ability to use effective coping mechanisms c. Expresses an understanding of the severity of their addiction d. Plans to associate with old friends only when they arent drinking e. Demonstrates an interest in staying involved in an appropriate support group

B, C, E The correct options show an understanding of the disease process and examples of needed skills as well as the commitment to maintain control over their addiction. The remaining options reflect promises but not true insight into the severity of their problem and the effects needed to manage it successfully. DIF: Cognitive Level: Application REF: Page 345 TOP: Nursing Process: Evaluation

1. Which interventions provided by the caregiver will help ensure effective care for the patient diagnosed with dementia? (Select all that apply) a. Taking the patients blood pressure regularly b. Being alert to ways the patient might be hurt c. Keeping the patient on a predictable schedule d. Assuming responsibility for meeting the patients needs e. Providing the patient with nonstimulating, private time

B, C, E These interventions take responsibility for areas in which the patient is incapable of providing self-care and addressing the special needs this patient has. Taking the blood pressure is not necessary unless there is a medical condition that requires doing so. Although the patients ability to provide self-care will deteriorate, independence should be encouraged as appropriate. DIF: Cognitive Level: Application REF: Page 383 TOP: Nursing Process: Implementation

1. A nurse is discussing unit expectations with a newly admitted patient diagnosed with poor impulse control. The nurse shows an understanding of the use of body language to convey feelings when documenting that the patient is angry and resistant to authority based on which of the following? Select all that apply. a. Patients reluctance to make eye contact b. Crossed-arm posture the patient assumes c. Quizzical expression on the patients face d. Sharp rapping of the patients fingers against the table e. Patients tendency to lean forward when seated in the chair

B, D Body language includes facial expressions, reflexes, body posture, hand gestures, eye movement, mannerisms, touch, and other body motions. Body posture and facial expressions, including eye movements, are two of the most important cues to determine how a person is responding to the message. This patients crossed-arm posture and sharp finger rapping are indicators of anger. Poor eye contract is recognized as poor self-esteem or guilt cues, whereas a quizzical expression is likely an indication of confusion. Leaning forward in the chair is generally viewed as a positive sign of interest and/or cooperation. DIF: Cognitive Level: Application REF: Page 65 TOP: Nursing Process: Assessment (Communication and Documentation)

2. Which nursing activities represent the tertiary level of mental health care? Select all that apply. a. Providing a depression screening at a local college b. Helping a mental-challenged patient learn to make correct change c. Reporting an incidence of possible elder abuse to the appropriate legal agency d. Regularly assessing a patients understanding of their prescribed antidepressants e. Providing a 6-week parenting class to teenage parents through a local high school

B, D Tertiary prevention reduces the residual effects of the disorder such as depression and mental retardation. There is no quaternary level of prevention. Primary prevention reduces occurrences of mental disorders such as screenings and parenting classes, and secondary prevention reduces the prevalence of disorders as evidenced by assessing knowledge. DIF: Cognitive Level: Application REF: Page 4 TOP: Nursing Process: Planning

; Physiological Integrity 15. The nurse is discouraged because the patient exhibiting negative symptoms of schizophrenia has shown no improvement with the planned interventions to reduce the symptoms. The mentors remark that helps place the problem in perspective is: a. You arent responsible for the behavior of any other person. b. Patients can be perverse and cling to symptoms despite our efforts. c. Negative symptoms have been associated with genetic pathology. d. It will take several trail and error attempts to get the right combination care.

C A complex disorder, such as schizophrenia, most likely has multiple contributing factors, including genetic predisposition, prenatal development, and the environment. Nurse frustration can be alleviated by helping the nurse realize that negative symptoms may be the result of actual brain dysfunction, rather than psychologically determined behaviors; thus the remaining options are not appropriate since they do not address the complexity of the problem. DIF: Cognitive Level: Application REF: Page 106 TOP: Nursing Process: Implementation

30. When asked, Why do you go to music therapy every morning at 10? The nurse explains that the nurses role in music therapy as: a. Fostering and encouraging performance talent b. Teaching patients about various styles of music c. Noting patient verbal and nonverbal expression of feelings d. Selecting and playing numbers that will reduce anxiety and stress

C A goal of music therapy is to promote expression and social connection. The nurse should observe and document expression of feelings as they occur. The observations may be used later, as a basis for further consideration by the nurse and patient. The other options do not reflect aspects of the nurses role in music therapy. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Implementation

9. Electroconvulsive therapy (ECT) has been prescribed for a patient diagnosed with chronic depression. Which statement by the patient helps assure the nurse that the patients right to informed consent has been respected? a. ECT treatment will cure my depression. b. ECT is dangerous but Im almost out of treatments. c. I may not remember things that happened just before the ECT treatment. d. Im likely to permanently lose memory of things like dates and numbers.

C A potential side effect is memory loss that is usually temporary but that can rarely be irreversible. It is not true that ECT either cures depression or that the treatment is considered physically dangerous. DIF: Cognitive Level: Application REF: Page 174 TOP: Nursing Process: Evaluation

9. Which activity shows that a therapeutic alliance has been established between the nurse and patient? a. The nurse respects the patients right to privacy when visitors are spending time with the patient. b. The patient is eagerly attending all group sessions and working independently on identifying their personal stressors. c. The patient is freely describing their feelings related to the physical and emotional trauma they experienced as a child with the nurse. d. The nurse dutifully administers the patients medications on time and with appropriate knowledge of the potential side effects.

C A primary aspect of working with patients in any setting and particularly in the psychiatric setting is the development of a therapeutic alliance with the patient. Such an alliance is established on trust. It is a professional bond between the nurse and the patient that serves as a vehicle for patients to freely discuss their needs and problems in the absence of the nurses criticism or judgment. Any nurse has an obligation to respect the patients rights and administer care effectively. The patients willingness to participate in the plan of care reflects self motivation. DIF: Cognitive Level: Application REF: Page 9 TOP: Nursing Process: Implementation

5. While discussing assessment of suicidal patients, a novice nurse mentions, I was taught to always base my care on concrete, evidence-based scientific reasoning and never to rely on intuition. Which response by the experienced nurse shows understanding of intuitive reasoning? a. Thats wise, because intuition went out of favor with the scientific revolution. b. Critical thinking and intuition are at opposite poles. Keep relying on your expertise. c. Its possible that intuition about suicidality is generated by transfer of feelings from the patient to the nurse. d. Its been determined that intuition is nothing more that extrasensory perception, so some folks have it, and some dont.

C A strong hunch or a gut feeling is an example of intuitive reasoning that is believed to come from the therapeutic relationships sharing of feelings between nurse and patient. Most nurses agree that intuition is compatible with scientific reasoning, because both are likely linked to practice and experience. A nurse learns intuitive reasoning through clinical practice rather than from school or books. DIF: Cognitive Level: Application REF: Page 45 TOP: Nursing Process: Analysis (Caring)

16. A patient with borderline disorder tells the nurse, Its hard to figure out who I am. Sometimes Im sexually attracted to women and sometimes to men. The nurse using Freudian concepts can analyze this as a developmental problem related to: a. Lack of separation-individuation b. Isolation of affect during latency c. Impaired development of sexual identity during the phallic stage d. Overdevelopment of latency stage traits related to control issues

C According to Freud, identifying ones sexual identity takes place during the phallic stage of development. When sexual identity is not clearly established, the individual may express confusion in sexual preference. The other options do not relate to information given in the scenario. DIF: Cognitive Level: Comprehension REF: Page 303 TOP: Nursing Process: Assessment

16. The head nurse in the ED has received word that a major fire in a high-rise office tower will result in many injured persons being brought to the hospital within the next few minutes. The head nurse tells the staff, You will need to assess for acute stress reactions as well as treating physical problems. Which patient is exhibiting symptoms characteristic of acute stress reaction? a. A male whose moods swing between mania and depression b. A female who reports still hearing her daughters pleas for help c. A male who keeps repeating I dont understand whats going on? d. A female who is rocking her young son and repeating it will be okay.

C Acute stress reactions are characterized by indications of dissociation, such as dissociative amnesia. Mood swings are more reflective of a mood disorder. Auditory hallucinations would be consistent with re-living a traumatic event. Comforting and reassuring a child in this manner is not characteristic of an acute stress reaction. DIF: Cognitive Level: Application REF: Page 196 TOP: Nursing Process: Assessment

12. A patient diagnosed with paranoid schizophrenia has been charged with murder. The patients mother asks, What will happen if my son is found not guilty by reason of insanity? Which response shows that the nurse understands the outcome of this plea? a. Your son will not receive the death penalty. b. He will receive the mental treatment he deserves. c. The court will order that he be involuntary committed for treatment. d. He is considered innocent and will be released to the care of his physician.

C After a person is found not guilty by reason of insanity, he or she is usually hospitalized and sent to a psychiatric unit for evaluation of commitability. Although they have been found not guilty, they have committed a criminal act and that will require appropriate punishment. DIF: Cognitive Level: Application REF: Page 178 TOP: Nursing Process: Implementation

: Reduction of Risk Potential 9. An appropriate intervention for a patient with an identified nursing diagnosis of situational low self-esteem would be: a. Providing large muscle activities to relieve stress b. Attempting to determine triggers to hallucinations c. Engaging patient in activities designed to permit success d. Encouraging verbalization of feelings in a safe environment

C All are useful interventions for a patient with schizophrenia; however, engaging the patient in specifically designed activities is the only option that addresses improving self-esteem. DIF: Cognitive Level: Application REF: Page 285 TOP: Nursing Process: Implementation

31. An experienced nurse correctly notes that an important factor in assessing survivors of childhood sexual abuse is to be aware that they often experience long-term symptoms most closely resembling DSM-IV-TR criteria for: a. Adjustment disorders b. Schizophreniform reaction c. Posttraumatic stress disorder d. Obsessive-compulsive personality disorder

C Although childhood sexual abuse produces a wide variety of long-term sequelae, the most common psychosocial problems are PTSD, self-damaging behavior, mood disturbances, interpersonal problems, and sexual difficulties. The other options are rarely noted. DIF: Cognitive Level: Application REF: Page 541 TOP: Nursing Process: Assessment

3. The nature of the communication characterized in this exchange between a nurse and a chronically depressed patient is: Nurse: Is it true that you enjoy knitting? Patient: Yes, Ive done it for years and am pretty good at it. Nurse: Im just a beginner. Do you think you could give me some tips? Patient: I guess so. What would you like to know? a. Therapeutic b. Collegial c. Social d. Intrapersonal

C Although the conversation takes place between the nurse and a patient, it is of a social nature. It is superficial and benefits both parties mutually by encouraging a relationship based on mutual interest. No expectation of help exists. Therapeutic communication promotes patient growth and is patient-focused. Collegial conversation occurs for the purpose of professional collaboration. Intrapersonal communication takes place within the individual. DIF: Cognitive Level: Comprehension REF: Page 66 TOP: Nursing Process: Implementation (Communication and Documentation)

3. A family member of a suicidal patient asks, Are there any medications that can prevent a person from committing suicide? Which statement best answers the question? a. If people want to harm themselves, they eventually will. b. Antipsychotic medications are used primarily for suicide prevention. c. Antidepressants treat mood disorders that accompany suicidal ideation. d. There are no medications available that specifically affect suicidal behavior.

C Although there is no medication to prevent suicide, the most constructive answer informs the family that mood disorders are often accompany by suicidal ideation, and antidepressants can treat these. Antipsychotic medications are not generally used for depression. The remaining option lacks empathy and does not accurately answer the question. DIF: Cognitive Level: Application REF: Page 504 TOP: Nursing Process: Implementation

10. A nurse, leading an inpatient group dealing with womens issues, identifies a patient who is assuming the role of aggressor. Which behavior characterizes this role? a. Attempting to manipulate others b. Mediating conflicts and disagreements c. Criticizing the contributions of others d. Seeking a position between contending sides

C An aggressor acts in negative ways, displaying hostility, attacking the group, or criticizing the members. Seeking a position between contending sides describes the compromiser. Mediating conflicts and disagreements describes the harmonizer. Attempting to manipulate others describes the dominator. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Assessment

14. By discharge, which outcome is appropriate for a patient who hears voices telling him he is evil? a. Respond verbally to the voices. b. Verbalize the reason the voices say he is evil. c. Identify events that increase anxiety and promote hallucinations. d. Integrate the voices into his personality structure in a positive manner.

C An appropriate outcome for a patient with hallucinations is recognition of events that precede the onset of hallucinations. Trigger events or situations usually cause increased feelings of anxiety. The remaining options are neither desirable nor appropriate. DIF: Cognitive Level: Application REF: Page 277 TOP: Nursing Process: Implementation

2. The nurse administering an antidepressant to a suicidal patient understands that the brain abnormality the medication addresses is: a. Atrophy of the brain b. Enlarged lateral ventricles c. Irregularities in the serotonin system d. Abnormal electroencephalogram (EEG) readings

C Antidepressants regulate serotonin levels, which is a chemical that is involved the development of depression. There is no research to support brain atrophy or enlarged lateral ventricles as being related to the development of depression. EEG readings are designed to assess the electrical activity of the brain. DIF: Cognitive Level: Comprehension REF: Page 504 TOP: Nursing Process: Implementation

2. The nurse suspects that the patients communication is being negatively influenced by personal attitude when he is heard stating: a. They think Im mentally ill but Im not; I just get a little depressed at times. b. I cant concentrate on anything besides getting out of here and back to my kids. c. Obviously my therapist cant understand where Im coming from because our lives are so different. d. There isnt anyone here in this hospital I can trust enough to talk to about why I abuse alcohol and drugs.

C Attitude determines how one person responds to another. It includes ones biases, past experiences, and openness. People of different socioeconomic backgrounds may have difficulty surmounting this barrier. The remaining options reflect factors that can negatively influence communication but they are environmental, knowledge, and relationship oriented. DIF: Cognitive Level: Application REF: Page 64 TOP: Nursing Process: Assessment (Communication and Documentation)

22. What response would be anticipated when a patient who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia is switched to Seroquel (quetiapine)? a. Development of pseudoparkinsonism b. Development of dystonic reactions c. Improvement in tardive dyskinesia d. Worsening of anticholinergic symptoms

C Atypical antipsychotics have been noted to block oral dyskinesia and improve tardive dyskinesia as well as improve both positive and negative symptoms of schizophrenia. Pseudoparkinsonism and dystonic reactions are associated with typical antipsychotic medication. Anticholinergic symptoms are not intense with the use of atypical antipsychotic medication. DIF: Cognitive Level: Application REF: Page 287 |Page 289 TOP: Nursing Process: Assessment

1. The nurse manager on the psychiatric unit was explaining to the new staff the differences between typical and atypical antipsychotics. The nurse correctly states that atypical antipsychotics: a. Remain in the system longer b. Act more quickly to reduce delusions c. Produce fewer extrapyramidal effects d. Are risk free for neuroleptic malignant syndrome (NMS)

C Atypical antipsychotics produce less D2 blockade; thus movement disorders are less of a problem. No evidence suggests that the medication remains in the system longer nor that it acts more quickly to reduce delusions. The atypicals are not risk free for NMS. DIF: Cognitive Level: Application REF: Page 567 TOP: Nursing Process: Implementation

3. A patient has been admitted with a diagnosis of hypoactive delirium. Which nursing intervention is supported by this diagnosis? a. Encouraging fluids to minimize constipation b. Frequently assessing both visual and auditory hallucinations c. Scheduling frequent changing of position to prevent skin breakdown d. Dimming the lights to help control eye discomfort resulting from cataracts

C Because of inactivity, hypoactive delirium patients are more likely to develop further complications, including decubiti that could be minimized by frequent repositioning. The remaining options identify interventions that are not generally a result of this diagnosis. DIF: Cognitive Level: Application REF: Page 377 TOP: Nursing Process: Planning

: Reduction of Risk Potential 33. Which statement made by a patient just prior to being transported for a scheduled ECT treatment would result in cancellation of the treatment? a. Ill be so glad when this treatment is over. b. Will I remember having this treatment? c. Did eating some crackers cause any problems? d. Im so tired of being depressed; I dont think I can go on.

C Because the patient is to receive general anesthesia and has orders to remain without food or liquids (NPO), the nurse should notify the physician immediately. The introduction of food into the stomach could result in aspiration of stomach contents during treatment. An expression of hopelessness related to depression would be reason to continue with the treatment. The other options offer no contraindication to treatment. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Implementation

10. When asked about the prognosis for a patient diagnosed with a dementia secondary to normal pressure hydrocephalus the nurse replies: a. Unfortunately the prognosis is for a downhill course ending in death. b. There will be good days and bad days for the rest of the patients life. c. The symptoms generally remit after a shunt is inserted to drain fluid. d. Well try our very best, but only time will tell how successful we are.

C By relieving the cause, the symptoms of secondary dementias are largely reversible. The statements reflected in the other options do not reflect this fact. DIF: Cognitive Level: Application REF: Page 367 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 29. A patient whose schizophrenia has been refractory to treatment with other medications has been placed on clozapine (Clozaril). The priority discharge teaching should include: a. Keep salt intake the same from day to day. b. Maintain a strict tyramine-free daily diet. c. Report for weekly blood tests for CBC level. d. Use sunblocking agents when out of doors.

C Clozaril has the potential to cause agranulocytosis; hence the need for weekly blood draws for CBCs for the first 6 months of therapy and every other week after that point. The other options are not relevant to Clozaril therapy. Salt intake refers to lithium therapy, tyramine to MAOI therapy, and sunblocking to phenothiazine therapy. DIF: Cognitive Level: Application REF: Page 573 TOP: Nursing Process: Planning

5. Which approach listed in the plan of care of a suicidal patient is considered a cognitive technique? a. Intense psychotherapy to deal with childhood issues b. Group therapy with patients with similar problems c. Limitation of negative thought patterns and increase of realistic self-evaluation d. Inclusion of significant others and family in the plan of care

C Cognitive techniques use examination of thought patterns and challenges to irrational or negative thoughts. The remaining options are not interventions that are supported cognitive therapy. DIF: Cognitive Level: Application REF: Page 517 TOP: Nursing Process: Implementation

25. Which measure consistent with the use of cognitive therapy could the nurse incorporate into the treatment plan of a chronically depressed patient? a. Approach the patient with cheerful affect and optimistic remarks. b. Ignore the patients pessimistic statements; give attention for positive thinking. c. Identify negative evaluations and challenge pessimistic beliefs. d. Seek to uncover unconscious conflicts about significant relationships.

C Cognitive therapy addresses symptom removal by identifying and correcting distorted negative thinking. An overly cheerful mannerism is an insensitive nontherapeutic approach that will reinforce patient negative thinking about self. To ignore negative statements while reinforcing positive thinking is considered a behavioral approach. Seeking to uncover unconscious conflicts is a psychodynamic approach. DIF: Cognitive Level: Application REF: Page 251 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 14. Which patient outcomes would be most applicable for the patient who has been taking benzodiazepines? Patient will state: a. That there are specific foods to avoid while on this medication b. An understanding of how to increase medication dosage c. That alcohol is a substance to avoid while on the medication d. An understanding that he or she can return to work while on this medication

C Combining a benzodiazepine with alcohol or other CNS depressant is potentially fatal. No food restrictions exist. Dosage should not be changed without consultation with the physician. Patients may return to work unless experiencing sedation. In this case, they would be cautioned not to operate machinery. DIF: Cognitive Level: Application REF: Page 589 TOP: Nursing Process: Outcome Identification

8. A patient tried to gouge out his eye in response to auditory hallucinations commanding, If thine eye offends thee, pluck it out. The nurse would analyze this behavior as indicating: a. Derealization b. Inappropriate affect c. Impaired impulse control d. Inability to manage anger

C Command hallucinations may be so intense that the patient cannot control the impulse to do what the hallucination tells him to do; thus the patient has impaired impulse control. This is not an anger management problem. Derealization is a feeling that the environment is distorted or unreal and not suggested in the scenario. No evidence of inappropriate affect is given. DIF: Cognitive Level: Application REF: Page 278 TOP: Nursing Process: Assessment

11. A patient, who has been charged with assault with intent to commit murder, has been hallucinating. Which question when answered correctly by the patient would show competency to stand trial for the crime? a. Can you describe your hallucinations? b. Were you ever sexually abused as a child? c. Can you describe for me the charges against you? d. Can you explain why you wanted to assault your brother?

C Competency to stand trial is a narrow concept based on the persons awareness of the legal process and the understanding of the criminal charges. The remaining options are concerned with the individuals symptoms, past experience, and motives rather than his ability to understand the legal processes. DIF: Cognitive Level: Application REF: Page 177 TOP: Nursing Process: Evaluation

1. A patient who was savagely attacked by a bear has no memory of the event. Which statement best explains the patients inability to remember the attack? a. The woman lost consciousness and was not cognitively aware of what happened during the attack b. The brain has produced a chemical anemia that will repress the memories of the attack indefinitely. c. The patient is unconsciously using a defense mechanism to protect against the repeated memory of the attack. d. It is a temporary suppression of the attack; her memory will return when she is physically and emotionally ready to handle the memories.

C Defense mechanisms are used unconsciously to protect us from threats to the physical, mental, and social aspects of ourselves. The memory of the event may or may not come back but this is not generally related to the patients ability to handle the memories. Memory may be lost or impaired as a result of brain trauma but not as likely from a chemical alteration. DIF: Cognitive Level: Application REF: Page 187 TOP: Nursing Process: Implementation

9. The nurse asks a patient admitted with a diagnosis of major depression, Do you feel like hurting yourself at this time? What is the primary rationale for obtaining this information when nothing in the referral note implied that the patient was suicidal? a. It is likely that he is hiding the desire to harm himself. b. This information must be reported to the patients physician. c. Specific safety measures must be implemented when self-harm is a danger. d. Patient safety is always the primary responsibility of the units nursing staff.

C Depression is a disorder linked to suicidal behavior, so it is imperative to ask and then closely observe the patient if he says Yes. The remaining options although true are not the primary rationale for assessing a depressed patient for suicidal ideations. DIF: Cognitive Level: Analysis REF: Page 510 TOP: Nursing Process: Assessment

5. A patient admits to having been battered by her live-in boyfriend several times over the past 2 years. She states to the nurse, We plan to get married next June, and I think things will be better then. He is always so sorry afterward, that I think I can trust him to change. Which intervention should be included in the patients teaching plan? a. Discourage her hope that the battering will end after they are married. b. Assist her in enrolling in a class to learn techniques of self-defense. c. Assist her in developing an emergency plan, because the pattern of violence is likely to continue. d. Emphasize that the battering pattern usually remains the same in frequency and severity over time.

C Developing an emergency plan is critical for any battered woman. The battering is not likely to cease unless the batterer seeks help but stating that fact is not therapeutic by itself. This will not stop the violence, although it might afford her some protection. Violence usually increases over time. DIF: Cognitive Level: Application REF: Pages 532-533 TOP: Nursing Process: Implementation

11. A patient with antisocial personality disorder yells, Shut up about that, or Ill punch you in the nose! and shakes his fist at another patient in a group meeting after the patient speaks negatively of illicit drug use. The nurse quickly determines that the patient is at risk to act violently against others as evidenced by his aggressive behavior, verbal threats, and a history of impulsivity. Which is the best approach for the nurse to use? a. Secluding the patient to protect the other patients and staff b. Putting the patient in restraints to protect the entire milieu c. Exploring alternate ways to handle frustrating topics in the group d. Telling the patient to leave the group until he can behave appropriately

C Discussing angry feelings in a group setting that is focused on exploring alternative problem-solving options will both distract the patient from angry feelings and help to focus energy on constructive activities. Seclusion and restraints are not necessary until verbal interventions prove unsuccessful. Making the patient leave the group is not an approach that will lead to meaningful learning. DIF: Cognitive Level: Application REF: Page 313 TOP: Nursing Process: Implementation

2. Which patient response would support the conclusion that the patient has moved into the dark side of a narcotic addition? a. Ive been abusing drugs for at least 10 years. b. Drugs makes me feel good; that why I use them. c. I dont like the way I feel when I dont use drugs. d. Drugs are something that I can either take or leave

C During beginning use (the light side), the feel good effects are dominant. As the individual becomes habituated to the drug, tolerance and withdrawal symptoms develop; this constitutes the dark side. The remaining options do not describe effects of drug use. DIF: Cognitive Level: Application REF: Page 325 TOP: Nursing Process: Assessment

2. The nurse will base a discussion of dysthymia on the fact that the condition: a. Typically has an acute onset b. Involves delusional thinking c. Is chronic low-level depression d. Does not include suicidal ideation

C Dysthymia is identified as a chronic low-level depression frequently lasting over a period of several years without remitting. Dysthymia has a slow, insidious onset. Delusional thinking is not a common manifestation of dysthymia. Suicidal thoughts are seen among dysthymic patients. DIF: Cognitive Level: Comprehension REF: Pages 232-233 TOP: Nursing Process: Implementation

16. Which nursing response would indicate an empathetic approach to a patient who is depressed over recent losses in her life? a. Losing a job isnt always a bad thing. b. I lost my parents last year and still feel sad. c. Please tell me more about what you are feeling. d. Lets not focus on whats sad but rather what is good about life.

C Empathy or empathic understanding is the nurses ability to see things from the patients viewpoint and to communicate this understanding to the patient. This response focuses on the patients feelings and encourages further discussion. Minimizing the loss or suggesting a change in focus sounds judgmental or patronizing and will likely cut off communication. Although self-disclosure can be therapeutic, this focuses on the nurses feelings. DIF: Cognitive Level: Application REF: Page 70 TOP: Nursing Process: Implementation (Communication and Documentation)

18. Which nursing intervention is most therapeutic when the nurse is managing the aggressive, disruptive behaviors of a manic patient whose attempts to control the milieu has been rejected by the other patients? a. Advising that the patient to accept the wishes of the group b. Suggesting that the patient either quiet down or leave the room c. Accompanying the patient to a quieter part of the unit d. Ignoring the patients outbursts because they are surly related to the mania

C Escorting the patient to a less stimulating environment will assist the patient to remain in control of behavior. It is unlikely that the patient would respond to verbal suggestions to leave the area unaccompanied or accept the groups wishes and would likely see the suggestions as a threat that would further escalate the impending loss of control. The behavior cannot be ignored since it will likely lead to an acceleration of the mania. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Implementation

35. A teenager is admitted to the adolescent unit with a diagnosis of adjustment disorder with depression. Which information collected from the assessment interview will be given highest priority when planning the patients care? a. Patient frequently disregards curfew. b. Patients parents were divorced 8 years ago. c. Patient states she finds no pleasure in living. d. Patient is failing most of her high school classes.

C Finding no pleasure in living should suggest the need for further assessment of suicide potential. Safety needs take priority over problems suggested by other data collected. DIF: Cognitive Level: Analysis REF: Page 238 | Page 246 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 9. Which patient complaint should receive priority from a patient who is taking the MAOI tranylcypromine (Parnate)? a. I havent had a bowel movement in 2 days. b. Will you take my temperature? I feel too warm. c. I get a headache when I drank several cups of coffee. d. My legs get stiff when I sit in the chair for any length of time.

C Hypertensive crisis may occur if a patient taking a MAOI ingests certain food containing tyramine or drugs that cause blood pressure (BP) elevation. Headache is a warning sign of hypertensive crisis. The nurse should assess BP and inquire about other symptoms of hypertensive crisis. Stiffness is not related to MAOI therapy. Elevated temperature is not an initial sign of hypertensive crisis. Constipation is not a sign of hypertensive crisis. DIF: Cognitive Level: Analysis REF: Page 580 TOP: Nursing Process: Assessment

32. The nurse manager, teaching a class to new staff members about working with patients with adjustment disorders, will specify that the intervention most helpful in working with patients with this diagnosis is: a. Entering pertinent data in the patients medical record b. Including family members in the interdisciplinary treatment plan c. Identifying the precipitating stressful event and current problems d. Reducing the patients level of anxiety to prevent behavioral escalation

C Identification of the precipitating stressful event and interpretation of the existing problem are fundamental to working with the patient to reduce symptoms. Including family in treatment planning is secondary to identification of the stressor and the problem. Anxiety will remain high until the problem and the stressor are identified. Data entry is not directly related to the question posed. DIF: Cognitive Level: Application REF: Page 238 TOP: Nursing Process: Implementation

26. Which behavior is supportive of a histrionic personality disorder? a. Withholding of feelings and low self-esteem b. Insistence on others conforming to own methods c. Engaging in impulsive acts like unprotected sex d. Initial charm dissolving into coldness and blaming others

C Impulsive sexual activities are characteristic of histrionic personality disorder. Low self-esteem is more indicative of avoidant behaviors. Inflexible methods are usually seen in obsessive-compulsive personality disorders. Alternating between charming and blaming describes some behaviors commonly seen in antisocial personality disorders. DIF: Cognitive Level: Application REF: Page 306 TOP: Nursing Process: Assessment

15. The nurse assesses a patients judgment by asking: a. Why did you run away? b. When did you first start hearing voices? c. What would you do if you smelled smoke in your home? d. Do you believe you hear voices, or do you think it is in your mind?

C Judgment is the ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions. Judgment may be assessed by asking a question that has a common-sense answer. The other options ask about motivation, elicits historical information about the illness or seeks information about insight. DIF: Cognitive Level: Application REF: Page 43 TOP: Nursing Process: Implementation

14. The nurse counsels a mother to allow her 2-year-old child to keep a blanket that he uses to comfort himself. The basis for this counseling is: a. Sullivans theory of good me b. Freuds developmental theory c. Mahlers theory of object relations d. Kernbergs conceptualization object constancy

C Mahlers theory of object relations suggests that the child at this age has a beginning sense of object constancy and can use a representation of the mother for comfort. The child may use a blanket or other object to remind himself of the mother. The other theories mentioned are not as clearly related as Mahlers. DIF: Cognitive Level: Comprehension REF: Pages 303-304 TOP: Nursing Process: Implementation

11. When caring for a patient admitted with a diagnosis if bipolar disorder, managed care regulations is the driving force behind the nurses use of: a. NANDA nursing diagnoses b. Short-term stress management therapy c. A specialized clinical pathway for such patients d. Generic instead of brand name medications

C Managed care regulations have brought about the use of clinical pathways (also called critical pathways or a care maps) which are standardized multidisciplinary planning tools that monitor patient care through projected caregiver interventions and expected patient outcomes with a projected timeline of success. NANDA nursing diagnoses are not related to regulations or payment concerns. The implementation of short-term stress management therapy in an acute care psychiatric environment would not be driven by managed care regulation or payment concerns. The use of generic medications when appropriate is primarily cost driven. DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: Implementation

14. A patient whose symptoms of mild depression have been managed with antidepressants is concerned about the affect of accepting a promotion that will require working the night shift. What will be the basis of the response the nurse gives to address the patients concern? a. The connection between a new job and possible depression does exist. b. The medication can be adjusted to manage any increase in depression. c. The interruption in normal wake-sleep patterns can influence mood disorders. d. The change in sleep routine can be managed with a healthy sleep hygiene routine.

C Many psychiatric and medical disorders occur more frequently or are exacerbated when sleep patterns and biologic rhythms are disrupted. While the remaining options contain true information regarding the management of depression that is a result of sleep disruption, they do not effectively address the patients concern. DIF: Cognitive Level: Application REF: Page 108 TOP: Nursing Process: Planning

3. The patient diagnosed with schizophrenia asks why psychotropic medications are always prescribed by the doctor. The nurses answer will be based on information that the therapeutic action of psychotropic drugs is the result of their effect on: a. The temporal lobe; especially Wernickes area b. Dendrites and their ability to transmit electrical impulses c. The regulation of neurotransmitters especially dopamine d. The peripheral nervous system sensitivity to the psychotropic medications

C Medications used to treat psychiatric disorders operate in and around the synaptic cleft and have action at the neurotransmitter level, especially in the case of schizophrenia, on dopamine. The Wernickes area, dendrite function, or the sensitivity of the peripheral nervous system are not relevant to either schizophrenia or psychotropic medications. DIF: Cognitive Level: Comprehension REF: Page 104 TOP: Nursing Process: Assessment

12. Which nursing intervention demonstrates an understanding regarding the primary form of substance use disorder among older adults? a. Assessing the patients hands and feet for the presence of both numbness and tingling b. Having the patient, describe your relationship with you adult children, co-workers, and friends. c. Asking, Please identify for me all the medications both prescribed and over the counter you regularly take. d. Evaluate the patients understanding of the possible health risks that alcohol and medication abuse has on ones health

C Misuse of prescription medications is the most common form of drug abuse among older adults. This population is especially vulnerable because of the multiple drugs that are often prescribed for medical conditions. The remaining options do not help identify the presence of multiple medications. DIF: Cognitive Level: Application REF: Pages 334-335 TOP: Nursing Process: Implementation

: Reduction of Risk Potential 38. A novice nurse who will be assessing a patient after electroconvulsive therapy (ECT) asks her mentor, What sort of memory impairment is present after several ECT treatments? The best response for the mentor would be: a. Its hard to say. Treatment affects everyone differently. b. Usually the patient has severe difficulty remembering remote events. c. Patients have mild difficulty remembering recent events, like what was eaten for breakfast. d. Both recent and remote memory is affected, producing profound confused, cognitive states.

C Most patients experience transient recent memory impairment after electroconvulsive therapy (ECT). The cognitive deficit becomes more pronounced as the number of treatments increases. When the course of treatments is completed, cognitive deficit generally improves to the pretreatment level. The other options are incorrect. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Implementation

7. The nurse would evaluate that patient education regarding lithium therapy for an individual with bipolar disorder as effective if the patient states: a. I can stop my lithium when I feel better. b. I can continue with my diuretic and cardiac medications. c. I will probably need to take the lithium for the rest of my life. d. I will taper my lithium when a therapeutic serum level is achieved.

C Most patients with bipolar disorder require long-term maintenance on lithium or other antimanic medication. Patients should never stop medication without consulting the physician. When a therapeutic level is achieved, the patient will continue on maintenance doses of lithium. Diuretics are contraindicated for the patient on lithium. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Evaluation

21. A novice mental health nurse shares that, Ill never get used to playing cards or other games with patients. It seems like a poor use of scarce nursing time. The best response for the nurses mentor would be: a. Perhaps youll want to rethink your transfer to this unit if youre really uncomfortable. b. Your comments make a point about scarce resources. Ill ask the treatment team to review our position on activities. c. Activity co-leadership puts us in a position to help patients develop social skills and support them as they take small risks. d. Managed care has cost us activities therapists. Activities are necessary to give patients something to do, so we have to fill in.

C Nurses who engage in co-leadership of therapeutic activities recognize that each activity contributes to outcome attainment. During activities, patients practice skills needed in life situations, process emotions, and give and receive validation and feedback. Suggesting a rethink is not supportive of the nurse. The remaining options do not acknowledge the value of activities therapy. DIF: Cognitive Level: Application REF: Page 617 TOP: Nursing Process: Implementation

21. During a treatment team meeting, the point is made that a patient with schizophrenia has recovered from the acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin (5HT2) excess will suggest that the patient receive: a. Haloperidol (Haldol) b. Chlorpromazine (Thorazine) c. Olanzapine (Zyprexa) d. Phenelzine (Nardil)

C Olanzapine is an atypical antipsychotic. Atypical antipsychotic medications are more effective than typical antipsychotics in blocking serotonin receptors and reducing the negative symptoms of schizophrenia. Haloperidol (Haldol) and chlorpromazine (Thorazine) are typical antipsychotic medications while phenelzine (Nardil) is an MAOI antidepressant. DIF: Cognitive Level: Application REF: Page 287 | Page 289 TOP: Nursing Process: Implementation

2. Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder (PTSD) would be considered a defining behavior and support such a diagnosis? a. Can describe the attack in great detail b. Experiences dramatic swings in affect c. Describes vivid flashbacks of being attacked d. Is preoccupied with the need to tell someone about the attack

C One defining behavior that is seen when an individual has PTSD is that the person re-experiences the traumatic event. This takes place by having recurrent and intrusive disturbing recollections of the trauma, including thoughts, images, or perceptions about the incident. The person sometimes experiences recurrent dreams of the incident and acts or feels as though the event was recurring in the present (flashback). Generally the PTSD patient cannot remember all the details of the trauma nor are they particularly interested in re-telling the events of the trauma. The patient generally has a very limited range of affect. DIF: Cognitive Level: Application REF: Page 196 TOP: Nursing Process: Assessment

4. When engaging in outcomes identification, the nurse: a. Interviews and collects patient-focused data b. Re-assesses the patients physical and emotional status evaluation c. Reviews the patients existing problems and projects the results of the nursing care d. Considers the patients presenting symptoms and identifies nursing-related problems

C Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses. DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: Implementation

4. Which intervention would the nurse implement when a patients frontal lobe is affected? a. Educating the patient on the affects of dopamine b. Helping the patient identify reasons for crying c. Assessing the patient for any suicidal ideations d. Evaluating the affects of medication on motivation

C Researchers believe that frontal lobe dysfunction is related to feelings of hopelessness and worthlessness, both of which are signs of suicidal thoughts. The remaining options are related to symptoms that are associated with the limbic system. DIF: Cognitive Level: Application REF: Page 504 TOP: Nursing Process: Planning

8. The nurse shows an understanding of the appropriate use of nursing outcomes regarding triggers for a patient diagnosed with chronic alcohol abuse when stating: a. Can you work on identifying three situations that cause you to abuse alcohol? b. Ill help you to identify three triggers for your drinking during todays session. c. Im pleased youve identified three situations that trigger your abuse of alcohol. d. Do you think you will be able to avoid the three triggers that cause you to drink?

C Outcomes sometimes referred to as behavioral goals are used to describe and evaluate the effectiveness of nursing interventions. The correct option shows that the patient was successful at accomplishing an outcome inferring the nursing interventions were successful. The remaining options do not indicate an evaluation of success or failure. DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: Evaluation

: Reduction of Risk Potential 41. Which intervention will the nurse implement in the first half hour after the patient has received ECT? a. Continually stimulate patient to respond, using physical and verbal means. b. Continue bagging patient to improve respiratory function until patient is responsive for 10 minutes. c. Reorient as necessary to time, place, and person as level of consciousness improves. d. Encourage walking and eating breakfast as quickly as possible.

C Patient memory is likely to be impaired in the immediate post-ECT period. Reorientation will be necessary to help the individual return to a functional state. Continual stimulation is not necessary. Bagging is unnecessary. The patient may be allowed to rest and recover at his own pace. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Implementation

15. A patient with OCD tells the nurse, Thinking these thoughts and doing all my rituals is beyond being silly. I have few friends and I know others laugh behind my back. I sometimes think I can control things, but I always find I cant. I dont know if I can continue to live this way. Which assessment question shows the nurse has an understanding of this patients priority risk? a. Are you feeling hopeless? b. Do you think you are socially isolated? c. Have you been thinking about hurting yourself? d. Do the rituals affect how you feel about yourself?

C Patients with anxiety disorders should always be assessed for the presence of depression and suicidal ideation, the priority risk to safety. This patient has admitted feeling powerless to control the symptoms, in addition to wondering if she can continue to live the way she has been. There is ample reason for asking about suicidal ideation. The remaining options address hopelessness, social isolation, and low self-esteem. While appropriate nursing concerns, they dont have the priority self-harm has for this patient. DIF: Cognitive Level: Analysis REF: Page 199 TOP: Nursing Process: Assessment

22. A psychiatric technician remarks to the nurse, That patient with dependent personality disorder is so clingy! The response by the nurse that will be helpful to the technician is: a. I think everyone feels that way. Its difficult to have someone clinging. b. Patients with personality disorders have little regard for the rights of others. c. The patient fears having to function independently without direction from someone else. d. The patient is so preoccupied with perfection and structure that shes afraid to do anything at all.

C Patients with dependent personality disorder have an all-encompassing need to be taken care of. This need causes submissive, clinging behaviors. By helping the technician understand that the patients behavior is need-based rather than purposely annoying, the technician will be better able to respond with empathy and care. Validating the remark shows neither acceptance nor empathy for the patient. The remaining options do not provide accurate learning for the technician. DIF: Cognitive Level: Application REF: Page 307 TOP: Nursing Process: Implementation

13. Which nursing diagnosis would relate to the primary nursing concern related to a recently written prescription for amitriptyline (Elavil) 50 mg tid? a. Anxiety b. Ineffective coping c. Risk for self-injury d. Chronic low self-esteem

C Patients with depression are at increased risk for suicide when they have been on antidepressant medication for 2 weeks, because they are regaining some energy but may not have achieved full therapeutic effect with mood improvement. Poor coping is important but it is not the priority. Evidence of noncompliance is lacking. The medication is not prescribed for anxiety disorders. DIF: Cognitive Level: Analysis REF: Page 246 TOP: Nursing Process: Diagnosis

10. Which assessment data would bring into question a patients statement that, I have only a few drinks on special occasions.? a. History of treatment for glaucoma b. Fasting serum blood glucose level of 182 mg/dL c. Patient reports numbness in hands and feet bilaterally d. Red rash observed over neck, shoulders, and upper chest

C Peripheral nerve deterioration in both hands and feet result from chronic alcohol intake. Peripheral neuropathy occurs in about 10% of alcoholics after years of heavy drinking causing the nurse to question the patients statement. The remaining options do not reflect symptomology generally associated with alcoholism. DIF: Cognitive Level: Application REF: Page 338 TOP: Nursing Process: Assessment

10. Prior to initiating medication therapy with phenelzine (Nardil), the nurse should plan to determine the patients: a. Mood and affect b. Activity level c. Cognitive ability to understand information about the medication d. Support network and its members willingness to participate in treatment

C Phenelzine (Nardil) administration requires strict adherence to a restricted diet. The patient must have the cognitive ability to understand the food and medication interactions that may cause a serious reaction. DIF: Cognitive Level: Application REF: Page 248 TOP: Nursing Process: Planning

5. A patient asks the nurse, My wife has breast cancer. Could it be caused by her chronic depression? Which response is supported by research data? a. Too much stress has been proven to cause all kinds of cancer. b. There have been no research studies done on stress and disease yet. c. Stress does cause the release of factors that suppress the immune system. d. There appears to be little connection between stress and diseases of the body

C Research indicates that stress causes a release of corticotropin-releasing factors that suppress the immune system. Studies indicate that psychiatric disorders such as mood disorders are sometimes associated with decreased functioning of the immune system. Research does not support a connection between many cancers and stress. There is a significant amount of research about stress and the body. Research has shown that there are some connections between stress and physical disease. DIF: Cognitive Level: Application REF: Page 107 TOP: Nursing Process: Implementation (Teaching and Learning)

10. A patient indicates that he is about to share information about his illness that is shocking and embarrassing. Which nursing intervention has priority in this situation in facilitating the communication process? a. Reassuring the patient that talking will be therapeutic b. Assuring the patient the information will be kept confidential c. Responding to the patients information in an accepting manner d. Providing the patient with a private place for the discussion to occur

C Responding to the patients information in a nonjudgmental, accepting manner will encourage continued therapeutic communication. The remaining options, although appropriate, will not have the same generalized affect on the communication process as the correct option. DIF: Cognitive Level: Application REF: Page 67 TOP: Nursing Process: Implementation (Communication and Documentation)

14. A patient is ordered medication therapy to manage the symptoms of anxiety disorder. Which statement by the patient indicates an understanding of the typical classification of medication prescribed for this disorder? a. Tricyclic antidepressants are particular good for panic attacks. b. I have to give up beer while taking monamine oxidase inhibitors (MAOIs). c. Selective serotonin reuptake inhibitors (SSRIs) help with panic attacks as well. d. Benzodiazepines are usually effective when taken for chronic anxiety like mine.

C SSRIs are the most widely prescribed medication to treat panic disorder. They are effective and have a low side-effect profile. Tricyclic antidepressants are not effective for panic attacks and have more side effects than SSRIs. MAOIs are effective but require knowledge of and compliance with a special diet and are not the first choice in this situation. Benzodiazepines are effective but produce alterations in sensorium and other side effects and are not used for long-term management. DIF: Cognitive Level: Application REF: Page 201 TOP: Nursing Process: Implementation

21. A patient with suspected seasonal affective disorder asks the nurse, Ive been feeling down for 3 months. Will I ever feel like myself again? The response that builds on an understanding of this disorder is: a. Spontaneous improvement usually comes in 6 months to a year. b. Can you tell me what you mean when you say feel like myself? c. People who have seasonal mood changes often feel better when spring comes. d. Usually patients with this disorder see improvement during the fall and winter.

C Seasonal affective disorder is a condition in which the patient experiences depression beginning in the fall, lasting throughout the winter, and remitting in spring in the northern hemisphere. Fall and winter is not reflective of any diagnostic category of mood disorder. Spontaneous improvement occurs only with the change of seasons and available sunlight. Questioning is a response that does not address the point of understanding SAD. DIF: Cognitive Level: Application REF: Pages 230 | Page 237 TOP: Nursing Process: Implementation

14. A patient was admitted and prescribed antidepressants for severe depression with feelings of hopelessness, helplessness, and suicidal ideation. When would the patient be at greatest risk for suicide during hospitalization? a. Within the first hour after admission and when family leaves b. At night after visitors leave and patients are allow in their room c. Within the first 24 hours after admission and as discharge approaches d. Within 48 hours of first expressing suicidal ideation and as therapy progresses

C Statistics show that the most dangerous times for a hospitalized patient who has the potential for self-harm is within the first 24 hours after admission and as the associated stress of discharge nears. DIF: Cognitive Level: Application REF: Page 513 TOP: Nursing Process: Assessment

7. The nurse is working with the family of a patient with obsessive-compulsive disorder (OCD). Which concept should the nurse incorporate in the teaching plan? a. The thoughts, images, and impulses are voluntary. b. The family should pay immediate attention to symptoms. c. The thoughts, images, and impulses tend to worsen with stress. d. OCD is a chronic disorder that does not respond to treatment.

C Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the patients life as much as possible. The symptoms are not under the patients voluntary control. It is nontherapeutic to immediately focus on the symptoms, since to do so contributes to secondary gain. OCD responds well to medication and therapy. DIF: Cognitive Level: Application REF: Page 198 TOP: Nursing Process: Planning

2. Which observation is supportive of a diagnosis of avoidant personality disorder? a. Talks about my three failed marriages b. Cries loudly whenever requests are denied c. Fears criticism from others, including staff d. Shows no remorse when accidentally breaking another patients bracelet

C Symptoms suggesting an avoidant personality disorder include fear of rejection, avoidance of relationships, and censorship of expression of thoughts and feelings because of fear of a negative reaction. Borderline personality disorder presents with unstable interpersonal relationships, labile affect, and complaints of emptiness. Patients with histrionic personality disorders are overly dramatic, manipulative, and attention-seeking. Patients with schizoid personality disorder are indifferent to and lack concern for interpersonal contacts. DIF: Cognitive Level: Application REF: Page 305 | Page 307 TOP: Nursing Process: Assessment

: Reduction of Risk Potential 35. Which statement by a patient who has given informed consent for ECT confirms that the patient understands the side effects of this treatment? a. I wont remember the pain. b. It will take several weeks before I feel good again. c. My short-term memory loss will be only temporary. d. I will be at increased risk for developing epilepsy later.

C Temporary impairment of recent memory is an expected side effect that occurs to some degree during the course of ECT. The other options suggest the patients understanding of treatment and side effects is flawed. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Evaluation

25. A psychiatric technician mentions to the nurse, All these patients with Axis II problems! It makes me wonder how so many mothers could have been such poor parents and messed up their kids so badly! The response by the nurse that helps put the development of personality disorders into perspective is: a. Parenting is the responsibility of fathers, too, so dont blame only mothers. b. Personality disorder is often related to sexual abuse that occurs without parental knowledge. c. There is some evidence to suggest a biologic component to personality disorders. d. Peer interactions may be more important in child development than parental involvement.

C Tests show that schizotypal and schizoid disorders may reflect neurointegrative or neurochemical dysfunction and that affective dysregulation found in a number of personality disorders may be a function of serotonin abnormalities and may be implicated in impulsivity, aggression, and suicidal tendencies. The other options are either untrue or unhelpful. DIF: Cognitive Level: Application REF: Page 305 TOP: Nursing Process: Implementation

19. When reviewing the history of a newly admitted patient diagnosed with severe chronic depression, the nurse is most concerned about patient safety issues when noting: a. The patients Axis II includes a diagnosis of mental retardation b. Documentation that the patient has been noncompliant regarding medications c. The patients current Global Assessment of Functioning (GAF) Scale rating is 9 d. Reference to a recent physical injury resulting from the patients impulsive behavior

C The Global Assessment of Functioning (GAF) Scale is one of the tools use to assess patient functioning and possible prognosis. It is coded on a numerical continuum, with 1 indicating little danger and 10 indicating severe or persistent danger, and possible suicidal potential. Mental deficiency may contribute to issues of safety but it is not a significant risk factor. Noncompliance may contribute to the patients depression but it is not the greatest concern identified. Although past history is considered a predictor of future behavior, this is more related to the safety of others than to the patient. DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: Assessment

4. Discharge preparation for a patient includes the administration of the Hamilton Anxiety Scale (HAS). When asked by the patient to explain the purpose of the assessment the nurse responds: a. It is an assessment tool used to evaluate the symptoms of anxiety. b. The tool is used to help confirm the diagnosis of anxiety disorder. c. This tool helps determine if your symptoms have improved with treatment. d. It helps identify the presence of any other disorder associated with anxiety.

C The HAS is a valid and time-tested tool that gives the most objective measure of the degree to which anxiety has been effectively treated. The HAS does not evaluate for symptoms of anxiety or act as a diagnosis tool for anxiety or another other associated disorder. DIF: Cognitive Level: Application REF: Page 202 TOP: Nursing Process: Implementation

; Psychological Integrity 18. To best facilitate interdisciplinary communication regarding the plan of care for a patient diagnosed with paranoid schizophrenia, the nurse: a. Requires weekly meetings of the care team b. Ensures the team includes members from all appropriate disciplines c. Uses the standardized NIC classification system of care interventions d. Recognizes the need for team access to patient records and makes them available

C The Nursing Interventions Classification (NIC) is the first comprehensive standardized classification of interventions. The NIC states that one should not change intervention labels and definitions so that there is no confusion across settings. Although not inappropriate, the remaining options do not directly minimize confusion related to communication. DIF: Cognitive Level: Application REF: Page 55 TOP: Nursing Process: Implementation

15. A patient recently discharged from an alcohol rehabilitation program is brought to the hospital in a state of prostration with severe throbbing headache, tachycardia, a beet-red face, dyspnea, and continuous vomiting. The patients significant other states the patient got sick about 15 minutes after drinking a glass of wine. The nurse should be guided in assessment by the suspicion that the patient: a. Is having a stroke b. Has alcohol intoxication c. Is reacting to disulfiram (Antabuse) d. Is exhibiting symptoms of cross-dependence

C The alcohol deterrent drug, Antabuse, commonly prescribed in recovering alcoholic treatment, causes this reaction when taken in combination with alcohol. Alcohol intoxication, stroke, and cross-dependence do not present with the listed prostration symptoms. DIF: Cognitive Level: Application REF: Page 337 TOP: Nursing Process: Assessment

27. A newly admitted patient with depression has been determined as suicidal and in need of one-to-one supervision. What is the best statement to inform the patient of the plan of care? a. A staff member will be with you at all times to watch you for suicide gestures. b. On this unit, a staff member stays with each new admission for the first 24 hours. c. We understand the impulse to attempt self-harm may be strong, so someone will stay with you to help you control the impulse. d. We are not sure you would be willing to tell a staff member if the urge to commit suicide becomes strong, so to prevent hospital liability someone will stay with you.

C The correct option explains the intervention in terms of the patients needs. Basing the intervention on the patients suicidal gestures is too threatening and intrusive. It is not true that all patients are observed for 24 hours. Identifying liability indicates that the staff is mostly worried about the hospital. DIF: Cognitive Level: Application REF: Page 517 TOP: Nursing Process: Implementation

21. The health care team is planning care for a patient hospitalized following a suicide attempt. Which statement by a team member should serve as a basis for planning? a. A patient who has made a recent suicide attempt is at low risk for another attempt. b. A patient who has made a recent suicide attempt is at very high risk for another attempt. c. A patient who has made a recent suicide attempt requires ongoing assessment to determine the level of risk. d. A patient who has made a recent suicide attempt may be at risk for 24 hours until medication takes effect.

C The correct option shows an understanding of the need for additional assessment in order to develop an effective plan of care. Assessment is needed to determine whether a patient is at high risk for another suicide attempt. The remaining options are incorrect. DIF: Cognitive Level: Application REF: Page 503 TOP: Nursing Process: Planning

8. An older adult is admitted to the hospital for severe depression. The nurse, gathering data for a medical and psychiatric history, learns of a suicide attempt 4 years ago after the death of a spouse. Based on this information, it is likely that the patient: a. Will avoid attempting suicide again after the past experience b. Will try to minimize the seriousness of the suicide attempt c. May express suicidal ideation or make a suicide attempt d. Will report that he has recently written a will

C The majority of persons who complete suicides have made previous suicide attempts. The remaining options are not supported by research that indicates the increased risk of suicide associated with a history of such behaviors. DIF: Cognitive Level: Application REF: Page 511 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 31. A patient receiving haloperidol urgently calls to the nurse and reports that his eyes have rolled upward and he cannot redirect his gaze. The nurse contacts the physician to seek an order for: a. Fluphenazine (Prolixin) b. Citalopram (Celexa) c. Benztropine (Cogentin) d. Risperidone (Risperdal)

C The nurse should recognize the patients problem as dystonia and know the treatment is IM administration of an antiparkinsonian drug, such as benztropine, or an antihistamine, such as diphenhydramine (Benadryl), for which a physicians order is necessary. Fluphenazine (Prolixin) would worsen the condition. The remaining options would not be useful. DIF: Cognitive Level: Application REF: Page 569 TOP: Nursing Process: Implementation

13. When sharing her feelings about separating from a therapy group, the patient stated, I feel a bit sad and empty that I wont be seeing you folks again. What is the most accurate evaluation of the patients statement? a. It indicates regression and her lack of readiness to terminate. b. Unconsciously, she is hoping she will be permitted to continue the group. c. She is demonstrating normal feelings associated with termination of therapy. d. She needs further evaluation by her therapist to determine readiness to terminate.

C The patient is expressing feelings of sadness over the loss of the therapeutic group relationships that have been helpful to her. Such feelings are considered normal, just as they are considered normal when the nurse-patient relationship terminates. The feelings expressed are normal, not regressive. No hidden meaning is present; the patient openly expressed genuine feelings. Further evaluation is not needed. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Evaluation

25. A patient who has been battered by her partner sobs, It was my own fault. Which of the following would be the priority response by the nurse? a. Why do you think he does it? b. What did you do to deserve this? c. No one has the right to abuse another. d. Tell me about when you were growing up.

C The patient must understand that as a human being she has the right not to be abused. Victims of abuse should be given this information in a respectful way to counteract their feelings of guilt and shame. Asking about behaviors suggests that the patient had a role in provoking the battery. Asking why sidesteps the real issue. Enquiring about her childhood continues to look at factors within the patient. DIF: Cognitive Level: Application REF: Page 530 TOP: Nursing Process: Implementation

1. When analyzing the behaviors of a 23-year-old who meets the criteria for antisocial personality disorder, the nurse recognizes that which nursing diagnosis would be pertinent to his care? a. Risk for self-mutilation b. Disturbed personal identity c. Impaired social interaction d. Social isolation

C The patient with antisocial personality disorder is impulsive, manipulative, and dishonest. Patients with this disorder are frequently involved in illegal matters. Self-mutilation and disturbed identity are more appropriate for patients with borderline personality disorder. Social isolation would apply more readily to Cluster A disorders. DIF: Cognitive Level: Comprehension REF: Page 306 TOP: Nursing Process: Diagnosis

15. A patient tells the nurse, I really like you. Youre the only true friend I have. The patients remarks call for the nurse to revisit the issue of: a. Trust b. Safety c. Boundaries d. Countertransference

C The patients remarks call for the nurse to remind the patient of the parameters of the nurse-patient relationship. The remark would also give the nurse the opening to go on to discuss the matter of friendship. The patients remarks do not suggest the need to deal with trust, safety, or countertransference. DIF: Cognitive Level: Application REF: Page 605 TOP: Nursing Process: Implementation

7. Which assessment observation supports a patients diagnosis of disorganized schizophrenia? a. Reports suicidal ideations b. Last relapse was 6 years ago c. Consistent inappropriate laughing d. Believes that the government is out to get me

C The presence of disorganization and inappropriate affect identifies this disorder as disorganized schizophrenia. The symptoms of residual schizophrenia have long periods of remission. Schizoaffective disorder presents with severe mood disorders along with symptoms of schizophrenia. Paranoid schizophrenia is characterized by persecutory or grandiose delusions. DIF: Cognitive Level: Application REF: Page 274 TOP: Nursing Process: Assessment

19. Which theory of etiology of Alzheimers disease, suggested by current research, might the nurse use to help a family understand that this disorder is not of psychosocial origin? Alzheimers disease is associated with: a. Abnormal serotonin reuptake b. Prion infection of gray matter c. -Amyloid protein deposits in the brain d. Excessive acetylcholine in the frontal cortex

C The prevailing theories of etiology of Alzheimers disease include the following: angiopathy and blood-brain barrier incompetence; neurotransmitter and receptor deficiencies of acetylcholine; abnormal proteins, specifically -amyloid and their products; and genetic defects. Neither serotonin nor prions are implicated as problems in Alzheimers disease. DIF: Cognitive Level: Knowledge REF: Page 368 TOP: Nursing Process: Assessment

7. A patient has been hospitalized and is now being mandated outpatient mental health treatment as a condition for discharge. Which intervention best addresses the nurses role of patient advocate when this patient resists the recommendation? a. Helping the patient identify advantages of outpatient versus inpatient therapy b. Sharing that outpatient therapy is less expensive than inpatient hospitalization c. Stressing that outpatient therapy can minimize the need for future hospitalization d. Discussing the patients opposition to outpatient treatment with the treatment team

C The purpose of mandating outpatient mental health treatment is to break the cyclic pattern of patients who, when discharged from an inpatient treatment facility, subsequently require readmission to the acute psychiatric care setting. While the other options reflect the nurse as advocate, they do not best address this patients situation. DIF: Cognitive Level: Evaluation REF: Page 170 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 24. During a psychiatric emergency, IM ziprasidone (Geodon) is administered to an assaultive patient. During the next 2 hours, it is of primary importance that the nurse assess for: a. Tardive dyskinesia b. Anticholinergic effects c. Orthostatic hypotension d. Pseudoparkinsonism

C The side effect most likely to appear is orthostatic hypotension related to alpha1 receptor blockade preventing peripheral blood vessels from automatically responding to positional change. Anticholinergic effects are of lesser concern. The remaining options are less likely to occur at this point in therapy. DIF: Cognitive Level: Application REF: Page 575 TOP: Nursing Process: Assessment

28. A patient in her early teens who is being treated for irritable bowel syndrome has just disclosed that she has been the victim of child abuse for 8 years. For what other condition should the nurse assess this patient? a. Schizophrenia b. Agoraphobia c. Posttraumatic stress disorder d. Obsessive-compulsive disorder

C The state of chronic hyperarousal caused by the abuse is the basis for three common outcomes of childhood abuse: PTSD, depression, and irritable bowel syndrome. The conditions mentioned in the other options are not related to child abuse. DIF: Cognitive Level: Application REF: Page 539 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 17. A patient who has received lithium for 3 weeks to control acute mania has the following symptoms: coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion. The priority nursing action should be to: a. Administer prn Cogentin to relieve the symptoms. b. Provide reassurance that the symptoms are transient. c. Obtain a stat lithium level; hold lithium pending results. d. Assist the patient to decrease the sodium in their daily diet.

C The symptoms the patient is experiencing are consistent with moderate lithium toxicity. The nurse should hold lithium, obtain a stat lithium level, and notify the physician. Cogentin is inappropriate; the symptoms are not EPS. The nurse may reassure the patient but cannot suggest that the symptoms will resolve over time. Minimizing salt would worsen lithium toxicity. DIF: Cognitive Level: Application REF: Pages 583-584 TOP: Nursing Process: Implementation

14. Which statement indicates that a novice nurse understands the purpose of therapeutic communication? My goal for communication with any patient is to: a. maintain relationships. b. mutually share information. c. promote growth and change. d. offer advice and make suggestions.

C Therapeutic communication is intended to assist the patient to grow and change. The other options are characteristics of social communication. DIF: Cognitive Level: Application REF: Page 67 TOP: Nursing Process: Planning (Communication and Documentation)

27. A patient with a personality disorder asks the nurse, Is it true I have an inherited brain disorder? The nurse replies, knowing that: a. There is proof that personality disorders are inherited. b. All persons with personality disorders display brain abnormalities. c. Individuals with personality disorders manifest some biological markers. d. Individuals with personality disorders show an error in brain glucose metabolism.

C There is a need for more research relating genetics and brain dysfunction to personality disorders. Although there are some biologic markers, none of the other options are true. DIF: Cognitive Level: Application REF: Page 305 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 20. A patient has been taking chlorpromazine (Thorazine) for the past 2 weeks. He drools, has hand tremors, and walks with a shuffling gait. The nurse would correctly attribute these behaviors to: a. Akinesia b. Tardive dyskinesia c. Pseudoparkinsonism d. Neuroleptic malignant syndrome

C These are symptoms of pseudoparkinsonism associated with dopamine blockade. Tardive dyskinesia occurs after long-term therapy. The remaining options are not associated with the symptoms mentioned. DIF: Cognitive Level: Application REF: Page 569 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 34. The nurse notes that a patient who has been receiving paroxetine (Paxil) for symptoms of major depression begins to behave in a confused and elated manner with the presence of restlessness, muscle jerking, and diaphoresis. The nurse should assess these symptoms as probable: a. Neuroleptic malignant syndrome b. Anticholinergic blockade c. Serotonin syndrome d. Dystonia

C These are symptoms of serotonin syndrome, a condition that requires medical intervention. The other options are not associated with SSRI therapy. DIF: Cognitive Level: Application REF: Page 577 TOP: Nursing Process: Assessment

31. A patient experiences intrusive, insulting auditory hallucinations. Which independent behavioral technique can the nurse teach the patient to employ when the voices are troublesome? a. Introduce a distraction like reading. b. Use positive talk to offset the insults. c. Sing or whistle to compete with the voices. d. Increase the daily dose of an antipsychotic medication.

C This action provides an alternative to listening to the voices and gives the patient a sense of control. The patient should not adjust medication independently. Reading will not be particularly effective, because the voices are uncontested in a quiet atmosphere. Positive talk is generally used to positively affect self-esteem. DIF: Cognitive Level: Application REF: Page 279 TOP: Nursing Process: Implementation

30. A toddler was brought to the hospital with a broken humerus and upper arm bruising. The childs father states that he shook the child while disciplining him to teach him to be quiet. An appropriate family-related nursing diagnosis is: a. Anxiety related to physical abuse b. Powerlessness related to inability to keep child quiet c. Impaired parenting related to unrealistic expectations for child d. Risk for impaired parenting related to harsh disciplinary methods

C This diagnosis is supported by data in the scenario. Violence has occurred, so a risk diagnosis is not appropriate. The remaining diagnoses are not supported by data. DIF: Cognitive Level: Application REF: Page 540 TOP: Nursing Process: Diagnosis

24. There are several suicidal patients on the psychiatric unit. When meal trays are returned to the kitchen, a serrated-edge knife is missing. The nurse to whom the aide reports this should: a. Acknowledge the information and be watchful for the remainder of the shift. b. Ask each of the patients on suicide precautions where the knife is hidden. c. Report the information to the charge nurse and suggest a unit search. d. Report the information to security and let them handle the matter.

C This is an important safety issue. Although being watchful is appropriate, it is not sufficient to ensure safety in this situation. Assuming that only the patients on suicide precautions would know about the knives is not a proper assumption. Security does not need to be called in at this time, so option d is incorrect. Searching the unit for the missing knife would be the safest option. DIF: Cognitive Level: Application REF: Page 517 TOP: Nursing Process: Implementation

8. A patient who is diagnosed with schizoid personality disorder is isolative, does not speak to her peers, and sits through the community meeting without speaking. Her mother describes her as shy and having few friends. Which would be an appropriate nursing diagnosis for this patient? a. Anxiety related to a new environment as evidenced by isolation and not talking with peers b. Ineffective coping related to new environment as evidenced by isolation and minimal interaction with others c. Impaired social interaction related to unfamiliar environment as evidenced by isolation and not talking with peers d. Disturbed thought processes related to a new environment as evidenced by isolation and minimal interactions with others

C This nursing diagnosis relates directly to her symptoms and their underlying pathology. Data are not present to support the other options. DIF: Cognitive Level: Application REF: Page 306 TOP: Nursing Process: Diagnosis

34. Which question would be most effective in helping a patient with an adjustment disorder identify the event that triggered the maladaptive response? a. Can you tell me about your support system? b. Have you ever been in psychotherapy before? c. Did you experience any stressful events recently? d. How do you usually handle problems in your life?

C This question will determine whether the patient is able to identify a particular stressor that has affected her life recently. Asking about support systems will help gain information about important persons in the patients life. History of psychotherapy will provide information about mental health. Previous methods will provide information about use of coping strategies. DIF: Cognitive Level: Application REF: Page 238 TOP: Nursing Process: Assessment

6. Which assessment data poses the greatest risk for injury in a patient who abuses alcohol? a. Takes a baby aspirin each morning b. Uses over-the-counter antihistamines for seasonal allergies c. Has been taking a tricyclic antidepressant for more than 2 years d. Took a narcotic for 1 week to manage postdental surgery pain

C Tricyclic antidepressants are strictly contraindicated with alcohol consumption because of their potential effect on cardiac function. Although aspirin increases bleeding times and antihistamines and narcotics increase sedation, the outcome of combining alcohol and these drugs is not as dangerous as that of the correct option. DIF: Cognitive Level: Analysis REF: Page 335 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 32. An appropriate outcome for trihexyphenidyl (Artane) therapy used in conjunction with high potency typical antipsychotic medication therapy is that the patient will: a. Demonstrate a brighter mood b. Be less sedated and drowsy c. Display fewer movement disorder symptoms d. Display decreased anticholinergic symptoms

C Trihexyphenidyl is used to treat extrapyramidal symptoms, such as pseudoparkinsonism. The other options are not expected outcomes of administration of this medication. DIF: Cognitive Level: Application REF: Page 570 TOP: Nursing Process: Outcome Identification

: Pharmacological and Parenteral Therapies 18. A patient with rapid cycling bipolar disorder is not responding well to lithium. The patient tells the nurse, It feels as though Ill never get well. I get better, and then I get worse. The reply that is based on knowledge of current therapy would be: a. Youre feeling very discouraged arent you? b. Its not all bad, is it? Sometimes you like being high. c. Another drug, valproic acid, is proving effective for rapid cycling. d. If your kidneys hold out, the lithium will eventually control the symptoms.

C Valproic acid is a first-line agent for the treatment of bipolar disorder. It is particularly effective with rapid cycling. The other options are not responsive to the question stem, which asks for knowledge of current therapy. DIF: Cognitive Level: Application REF: Page 583 TOP: Nursing Process: Implementation

7. If an individual is admitted with a diagnosis of Wernicke-Korsakoffs syndrome, the nurse would expect to assess: a. Peptic ulcer b. Vivid illusions c. Cognitive deficits d. Auditory hallucinations

C Wernicke-Korsakoffs syndrome includes a severe form of amnesia and an inability to learn new skills which reflects a cognitive impairment. The other options are not associated with the syndrome. DIF: Cognitive Level: Comprehension REF: Page 338 TOP: Nursing Process: Assessment

6. A patient diagnosed with schizophrenia is hospitalized under an emergency commitment. Which nursing explanation is most effective when the patient asks, Why am I being kept here? a. The court believed you needed mental health care. b. Your mental condition became unstable and you relapsed. c. You couldnt stop doing things that could likely have hurt you. d. Id suggest that you exercise your patient right to speak to a lawyer.

C When the effects of the patients mental illness result in an immediate risk of self-harm or harm to others, an emergency commitment is appropriate. While it is correct that such a commitment is court ordered and may be a result of a relapse, these options do not appropriately respond to the patients question. The patient does have a right to a lawyer, but this option fails to answer the patients question as well. DIF: Cognitive Level: Application REF: Page 170 TOP: Nursing Process: Implementation

25. To maximize therapeutic care to a newly admitted suicidal patient on days 1 and 2 of hospitalization, the nurse will: a. Select appropriate community resources for referral. b. Identify patient areas of weakness and deficiency. c. Encourage the patient to express psychological pain. d. Refute delusional thinking by logical argument and reinforcement.

C With a newly admitted patient, listening to expressions of pain will be one of the first interventions for the nurse in order to support the assessment process. It is too soon to consider community resources. Identifying weaknesses is not a helpful intervention for a suicidal patient. There is no data supporting delusional thinking. DIF: Cognitive Level: Application REF: Page 518 TOP: Nursing Process: Implementation

1. What assessment data would reinforce the diagnosis of temporal lobe injury in patient who experienced head trauma? Select all that apply. a. Inability to balance a checkbook b. Uncharacteristically aggressive c. Affect fluctuates dramatically d. Increased interest in sexual behaviors e. Difficulty remembering the names of family members

C, D, E The temporal lobe is involved with memory as well as increased sexual focus and altered emotional responses. Personality and intellectual function is not centered in the temporal lobe. DIF: Cognitive Level: Application REF: Page 101 TOP: Nursing Process: Assessment

3. Which intervention reflects attention being focused on the patients intentions regarding his diagnosis of severe depression? a. Being placed on suicide precautions b. Encouraging visits by his family members c. Receiving a combination of medications to address his emotional needs d. Being asked to decide where he will attend his prescribed therapy sessions

D A primary factor in patient treatment includes consideration of the patients intentions regarding his or her own care. Patients are central to the process that determines their care as their abilities allow. Under the guidance of PMH nurses and other mental health personnel, patients are encouraged to make decisions and to actively engage in their own treatment plans to meet their needs. The remaining options are focused on specifics of the determined plan of care. DIF: Cognitive Level: Application REF: Page 5 TOP: Nursing Process: Implementation

8. The treatment team was engaged in planning how group therapy could be included as a part of the structured daily activities of the unit. A new team member asked, Why is it so important to include group therapy for the patients? The most accurate response would be based on the assumption that: a. Hidden agendas frequently surface in group sessions. b. Some persons do not relate well on an individual basis. c. Group therapy is far more cost-effective for the patients. d. Psychopathology has its source in disordered relationships.

D A key assumption of group therapy is that psychopathology has its source in disordered relationships. It follows that individuals will behave in the group as they do in other settings, so group provides an opportunity to help individuals develop more functional relationships. Ability to relate is not relevant to group work. It is dealt with in one-to-one therapy. Hidden agenda is not a reason to offer group therapy. Cost-effectiveness is not an assumption about the reason group therapy is effective. DIF: Cognitive Level: Application REF: Page 609 TOP: Nursing Process: Planning

24. To effectively plan care for a patient, the nurse will understand that activity and adjunct therapies may be more useful in some situations than verbal therapies because adjunct therapies: a. Are readily available in the treatment setting b. Do not require specific training or expertise to facilitate c. Provide the patient the opportunity to use ego-protective mechanisms d. Allow the patient to express feelings on multiple levels at the same time

D A patient is able to express feelings on the emotional, physical, and symbolic levels during activity therapy, whereas verbal therapies are limited to one dimension. The primary facilitator of the selected therapy is required to have formal education and supervised experience. Adjunct therapy does not provide this opportunity, which would be considered nontherapeutic. Treatment settings are not always readily available. DIF: Cognitive Level: Application REF: Page 617 TOP: Nursing Process: Planning

16. The Emergency Department nurses were discussing a patient who seeks help almost every holiday by expressing suicidal ideation or making a suicide gesture. One of the nurses stated, I dont think he is serious about hurting himself. Maybe we should not see him the next time he comes. Which response from the charge nurse is accurate in dealing with the patient who may be using suicidal behavior as a ploy to enter the hospital? a. He obviously needs the support he gets at the hospital. b. We should avoid showing any warmth the next time he comes in. c. Telling him we cannot see him may be the answer to stop this behavior. d. Each episode must be individually evaluated, and all options must be explored.

D A patient who has a history of suicide gestures or attempts is at greater risk for using this behavior style again. This is unsafe behavior that needs to be evaluated. It is true that the patient is in need of support but that answer does not address the issue of the misconception expressed by the nurses statement. The remaining options are unprofessional and totally lacking in therapeutic understanding of suicide. DIF: Cognitive Level: Application REF: Page 511 TOP: Nursing Process: Implementation

: Basic Care and Comfort 31. Care planned for a patient with adjustment disorder will be most effective if the nurse knows adjustment disorders are a group of disorders that: a. Involve psychotic thinking in adolescents b. Address issues of anxiety and depression c. Include behaviors that are seen primarily in the child and adolescent population d. Manifest as transient episodes of dysfunction in response to specific stressors

D Adjustment disorders are short-term disturbances in mood or behavior resulting from identifiable stressors. Psychotic features are not present. Adjustment disorders can occur in any age group. Anxiety and depression may be present, but emphasis is on identifying and resolving the specific issue. DIF: Cognitive Level: Comprehension REF: Page 238 TOP: Nursing Process: Planning

: Pharmacological and Parenteral Therapies 7. A severely depressed patient has been prescribed clomipramine (Anafranil). For which medication side effects should the patient be monitored? a. Excess salivation and drooling b. Muscle rigidity and restlessness c. Polyuria and coarse hand tremors d. Orthostatic hypotension and constipation

D Alpha1 blockade produces orthostatic hypotension, and cholinergic blockade produces constipation. Mild tremors and urinary retention may occur. Drooling and excessive salvation may occur with SSRIs. Muscle rigidity and restlessness may occur with antipsychotics. DIF: Cognitive Level: Application REF: Page 578 TOP: Nursing Process: Evaluation

2. What would be an appropriate short-term outcome for a patient diagnosed with residual schizophrenia who exhibits ambivalence? a. Decide their own daily schedule. b. Decide which unit groups they will attend. c. Choose which clinic staff member to work with. d. Choose between two outfits to wear each morning.

D An early step would be to make choices about nonthreatening matters when presented with limited alternatives. The remaining options represent decisions that are too complicated for the patient to make initially. DIF: Cognitive Level: Application REF: Page 285 TOP: Nursing Process: Outcome Identification

29. The nurse is collecting the paintings from the patients after the art session is over. After art therapy, a patient hands the nurse a paper that consists of several black scribbles. Which statement demonstrates the nurse understands the goals and objectives of the therapy? a. Do you want to complete your painting? b. I see that you dont take this very seriously. c. Can you tell me what happened to prompt such work? d. Thank you. Ill put this away in a safe place for you.

D Art therapy is used to help resolve conflicts and promote self-awareness. The nurse should not comment on the quality of the art or the patients talents, but rather treat the project with respect and value. The work is simply each patients self-expression. The other options make judgments about the work or the patients willingness to participate. DIF: Cognitive Level: Application REF: Page 619 TOP: Nursing Process: Implementation

1. A newly admitted patient has the diagnosis of catatonic schizophrenia. Which behavior observed in the patient supports that diagnosis? a. Uses a rhyming form of speech b. Refuses to eat any unwrapped foods c. Laughs when watching a sad movie d. Maintains an immobilized state for hours

D Catatonic schizophrenia is characterized by extremes of psychomotor activity ranging from frenzied behavior to immobilization and may include echopraxia and posturing. Paranoid thinking is characteristic of paranoid schizophrenia. Inappropriate affect and clanging are seen in disorganized schizophrenia. DIF: Cognitive Level: Application REF: Page 274 TOP: Nursing Process: Assessment

12. A benefit of the implementation of clinical pathways is evidenced when the patient states: a. I know my doctors and nurses really care about me. b. My medication has really helped lessen my symptoms. c. I have hopes that I will be able to lead a productive, healthy life. d. My care team has really helped me manage most of my problems.

D Clinical pathways are tools that among other things promote interdisciplinary care thus providing for holistic care of the patient. The remaining options do not involve the additional recognized benefits of clinical pathways that include cost effectiveness and access to patient status reports. DIF: Cognitive Level: Application REF: Page 54 TOP: Nursing Process: Evaluation

: Reduction of Risk Potential 1. A patient diagnosed with moderate dementia consistently appears to be distorting the truth resulting in his wife asking, What should I do when he lies to me about unimportant things? Upon what rationale should the nurses response be based? a. Changing the topic provides diversion. b. Delusions should be confronted to clarify thinking. c. Ignoring memory deficit avoids catastrophic reactions. d. This isnt lying but rather a way to fill in the memory gaps.

D Confabulation is not lying but rather a method for filling in the memory gaps. Ignoring, using confrontation, and changing the topic would not be as useful as gently reorienting. DIF: Cognitive Level: Application REF: Page 374 TOP: Nursing Process: Implementation

23. The nurse manager suspects that a novice nurse is experiencing countertransference regarding a chronically ill, psychotic patient. Which response is most effective at this time? a. I realize this is a difficult situation but it will occur again if you dont manage it now. b. I want you to see our hospital counselor so that you can regain your professional attitudes. c. I believe you are no longer able to be therapeutic so Im changing your patient assignment. d. Id like to help you begin to self-reflect on the feelings you seem to have for this patient.

D Countertransference is an emotional response on the part of the nurse that is a result of certain qualities in a specific patient. The response is dramatic, irrational, and inappropriate. The initial response would be for the nurse to engage in a self-assessment that focuses on why these feelings are occurring. It is true that the nurse needs to manage the situation but will need some guidance regarding how to accomplish that. If self-reflection isnt successful, then professional counseling would be the appropriate step. Changing the nurses assignment is not an effective means of managing the problem because it is a situation that reoccurs in nursing practice. DIF: Cognitive Level: Application REF: Page 78 TOP: Nursing Process: Implementation (Communication and Documentation)

: Pharmacological and Parenteral Therapies 27. When a patient for whom haloperidol has been prescribed tells the nurse, Im burning up and my muscles are stiff and sore, the nurse suspects neuromuscular malignant syndrome and recognizes the possibility that the physician may order: a. Olanzapine (Zyprexa) b. Benztropine (Cogentin) c. Venlafaxine (Effexor) d. Dantrolene (Dantrium)

D Dantrolene, a direct-acting skeletal muscle relaxant, is a drug often used to treat NMS. The other drugs mentioned would have no therapeutic effect on NMS. DIF: Cognitive Level: Application REF: Page 571 TOP: Nursing Process: Planning

; Physiological Integrity 11. Which explanation for the prescription of donepezil (Aricept) would the nurse provide for a patient in the early stage of Alzheimers disease? a. It will increase the metabolism of excess GABA. b. Excess dopamine will be prevented from attaching to receptor sites. c. Serotonin deficiency will be managed through a prolonged reuptake period. d. The acetylcholine deficiency will be managed by inhibiting cholinesterase.

D Decreased levels of acetylcholine are thought to produce many of the behavioral symptoms of Alzheimers disease. The inhibiting action the drug has on cholinesterase will slow down the breakdown of acetylcholine and so delay the onset of symptoms. The other neurotransmitters (GABA, dopamine, and serotonin) are not currently believed to play a role in Alzheimers disease. DIF: Cognitive Level: Application REF: Page 107 TOP: Nursing Process: Implementation

: Basic Care and Comfort 4. Which nursing diagnosis is appropriate for a patient who insists being called Your Highness and demonstrates loosely associated thoughts? a. Risk for violence b. Defensive coping c. Impaired memory d. Disturbed thought processes

D Delusions and loose associations suggest disturbed thought processes. The other options are not supported by data in the scenario. DIF: Cognitive Level: Application REF: Page 278 TOP: Nursing Process: Diagnosis

5. Which initial short-term outcome would be appropriate for a patient who was admitted expressing delusional thoughts? a. Accept that delusion is illogical. b. Distinguish external boundaries. c. Explain the basis for the delusions. d. Engage in reality-oriented conversation.

D Delusions are not reality oriented; thus an appropriate outcome would be that patient will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Patients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the patient still holds to the belief. DIF: Cognitive Level: Application REF: Page 286 TOP: Nursing Process: Outcome Identification

15. Which statement made by the patient who attempted suicide best indicates that the criterion for discharge has been met? a. I know who to call if I get depressed again. b. Ive learned that there is hope and I dont have to hurt. c. I have good friends who are willing to help me with my problems. d. I do not feel like harming myself anymore and that feels so comforting.

D Denying a need to harm oneself is a clear statement from the patient that he or she is feeling more positive. The remaining options although positive are not as good an indicator for discharge because they do not address the issue of self-harm. DIF: Cognitive Level: Analysis REF: Page 514 TOP: Nursing Process: Evaluation

20. The nurse is administering donepezil (Aricept) to a patient with stage 1 Alzheimers disease. Based on this drugs mechanism of action, the nurse will seek evidence of improvement in the patients: a. Social behaviors b. Existing delusions c. Ability to tolerate stress d. Ability to remember recent events

D Donepezil is a cholinesterase inhibitor that increases the concentration of acetylcholine. Acetylcholine is needed for intact memory and for learning. This medication is not prescribed for the conditions identified in the remaining options. DIF: Cognitive Level: Comprehension REF: Pages 385-386 TOP: Nursing Process: Assessment

25. Which intervention will the nurse plan for when managing the detoxification of a patient diagnosed with chronic alcoholism? a. Low-protein diet to minimize risk of kidney failure b. Seclusion to help manage aggression towards others c. Transporting patient to scheduled 12-step support group meetings d. Administering Ativan (lorazepam) to manage alcohol withdrawal symptoms

D During the process of detoxification, the nurse gives enough of a drug (or one to which the person has cross-tolerance) to relieve the withdrawal symptoms. Benzodiazepines like lorazepam (Ativan) have a cross-tolerance with alcohol, so they are used to manage withdrawal symptoms. The detoxification diet would be high in protein. Seclusion would not be initiated before less severe attempts to manage the behavior failed. Attending a support group would not be appropriate for the detoxification stage of rehabilitation. DIF: Cognitive Level: Application REF: Page 350 TOP: Nursing Process: Planning

23. A patient was admitted to a dementia unit after persistently wandering away from home. Which intervention will best address this patients risk for injury? a. Place the patient in a geriatric chair with a tray across the lap. b. Provide one-to-one supervision when the patient is ambulatory. c. Reinforce verbal explanation to the patient concerning the dangers of wandering. d. Activate alarm system that will alert staff to the patients attempt to open the door.

D Electronic alarms allow patients freedom of movement although still preventing them from wandering off the unit. One-to-one supervision is not necessary in an environment designed as a dementia unit. The geriatric chair would be an unacceptable form of restraint for this patient. The patient would not be capable of processing the verbal explanation. DIF: Cognitive Level: Application REF: Page 375 TOP: Nursing Process: Planning

12. A novice nurse asks, What is so wrong about being sympathetic with a patient who has also lost a parent like I did? The psychiatric nurse manager responds: a. There is a fine line between empathy and sympathy that when crossed makes you less able to be therapeutic. b. Rather than discussing the loss of your parent with the patient, you can talk to me about it whenever you need to. c. Ill provide you with some excellent materials that Im sure will help you to understand why sympathy is less therapeutic. d. Sympathy indicates that you are sharing your personal feelings and that changes the focus of the communication from the patient to you.

D Empathy should not be confused with sympathy. Sympathy is overinvolvement and sharing your own feelings after hearing about another persons similar experience. It is not objective, and its primary purpose is to decrease ones own personal distress. Although substituting sympathy for empathy does lessen the ability to be therapeutic, that is not the best explanation for avoiding it. Offering to discuss the nurses loss is a kind gesture but does not address the nurses question. Providing materials on the subject would be an appropriate reinforcement but does not address the question well. DIF: Cognitive Level: Application REF: Page 70 TOP: Nursing Process: Implementation (Communication and Documentation)

1. An example of an environmental factor that would cause a nurse to modify a planned critical interaction occurs when the: a. Patient expresses a personal dislike for the nurse b. Patient is in total denial about her condition c. Nurse lacks the degree of knowledge required for the interaction d. Nurse learns that the patients mother has been hospitalized with a stroke

D Environmental factors include timing. Timing of critical interventions is important. It should occur when the individual can give full attention to the topic. It would be inappropriate to continue with the plan in the face of the patients distress related to her mothers illness. The remaining options reflect other types of factors that influence communication such as attitudes, knowledge, and relationships. DIF: Cognitive Level: Application REF: Page 63 TOP: Nursing Process: Planning (Communication and Documentation)

; Psychological Integrity 22. Care planning for a patient diagnosed with paranoid schizophrenia will include: a. Analyzing effectiveness of care provided b. Determining the patients needs and problems c. Establishing realistic patient-focused outcome criteria d. Identifying priorities of care based on the patients condition

D Establishing priority nursing diagnoses is part of the process of planning. Determining needs is part of assessment. Analyzing effectiveness is an evaluation activity. Establishing realistic expectations is part of outcome identification. DIF: Cognitive Level: Application REF: Page 51 TOP: Nursing Process: Planning

; Psychosocial Integrity 8. During the termination phase of the nurse-patient relationship with a dependent patient, the nurse evaluates the effectiveness of coping techniques learned by: a. Role playing with the patient in order to practice being assertive b. Asking the patient to define the difference between being assertive and being aggressive. c. Discussing how her father effectively used both assertiveness and aggressiveness to control her d. Asking, When you used assertiveness to deal with your father during his visit, how did it work?

D Evaluation is a task of the termination phase. Asking such a question encourages patients to evaluate actions and look at the outcomes of behaviors. Role playing to practice the technique, defining the relevant terms, and discussing the effects of the fathers behavior would occur during the working phase of the relationship and does not encourage evaluation of the newly learned skills. DIF: Cognitive Level: Application REF: Page 75 TOP: Nursing Process: Evaluation (Communication and Documentation)

14. The nurse best fulfills the obligation to be accountable for providing care that meets the expected standards of care when: a. Developing a therapeutic relations with the patient b. Applying evidence-based nursing practice to the plan of care c. Providing appropriate discharge planning to meet the patients needs d. Evaluating the effectiveness of interventions through achievement of outcomes

D Evaluation of the patients progress and the nursing activities involved are critical because nurses are accountable for the standards of care in each discipline. Although the other options reflect appropriate and expected nursing interventions, they are not the primary means of assuring that standard of care has been met. DIF: Cognitive Level: Application REF: Page 56 TOP: Nursing Process: Planning

22. A Chinese-American patient comes to the mental health clinic after referral by her primary care physician. She complains of nervousness, headaches, fatigue, and vague GI symptoms for which no organic basis has been established. The symptoms began about 9 months ago when her favorite aunt died. The most appropriate independent nursing action would be to: a. Prescribe a trial course of antianxiety medication. b. Plan strategies for cognitive behavioral therapy. c. Arrange admission to the inpatient unit for a complete workup and psychologic testing. d. Confer with the psychiatrist about the cultural association between depression and somatic symptoms.

D Expression of symptoms is influenced by ethnicity and culture. When depressed, Asian and Asian-American patients describe somatic symptoms, whereas patients of Western cultures may focus on mood and cognitive symptoms. Option d is an appropriate independent intervention the nurse should take. Options a, b, and c would be considered collaborative, rather than independent, interventions. DIF: Cognitive Level: Application REF: Page 228 TOP: Nursing Process: Implementation

2. A new nurse asks the mentor, How can I be sure Im developing a therapeutic environment for my unit? The mentor uses as a basis for the response the fact that a therapeutic milieu is characterized by: a. Rigid adherence to timelines and unit routine b. Relaxation of boundaries when doing so is accepted by all c. The focus of the staff is directed to the most critically disturbed patients d. Specific patient-centered goals are established mutually by patient and staff

D Factors that determine the therapeutic effectiveness of the social environment includes the presence of two-way communication between the patients and the members of the multidisciplinary team for purposes of goal setting. In a therapeutic relationship, boundaries are established early and maintained throughout and although adherence to routine is important, there is room for adjustment when it benefits the therapeutic nature of the milieu. Although short-term attention may require focus on the patient in crisis, attention of the staff is equally shared. DIF: Cognitive Level: Application REF: Page 604 TOP: Nursing Process: Implementation

7. When an elderly patient is brought into the Emergency Department by family members who reported a fall the nurse became suspicious that the patient had suffered physical abuse. The patient denied that she had been abused. Her denial is most likely based on her: a. Feeling that she deserved the physical abuse b. Strong belief that nothing could be done to help her c. Lack of trust that the situation could ever be changed d. Fear of the possibility of being removed from her family

D Fear of being separated from family and institutionalized is a powerful motive that keeps elders from revealing abuse. The other options may be factors in some cases but they are not primary motivators of silence. DIF: Cognitive Level: Analysis REF: Page 544 TOP: Nursing Process: Assessment

6. Which of the following interventions should the nurse plan to use to reduce patient focus on delusional thinking? a. Confronting the delusion b. Refuting the delusion with logic c. Exploring reasons the patient has the delusion d. Focusing on feelings suggested by the delusion

D Focusing on feelings suggested by the delusion will help meet patient needs and help the patient stay based in reality. This technique fosters rapport and trust while discouraging the belief without challenging or refuting it. DIF: Cognitive Level: Application REF: Page 286 TOP: Nursing Process: Planning

17. Which observation seen in a teenage patient supports the suspicion of anabolic steroid abuse? a. Lack of facial hair b. Ritualized hand washing c. Stealing and hiding a magazine belonging to another patient d. Throwing a chair when told it was time to turn off the television

D For all individuals abusing anabolic steroids, extreme mood swings occur, and these may be accompanied by violent behaviors. Obsessive-compulsive behaviors and stealing are not generally associated with this disorder. The increased hormone presence would result not in a lack, but rather an increase, in facial hair. DIF: Cognitive Level: Application REF: Page 341 TOP: Nursing Process: Assessment

18. A nurse and patient are entering the termination phase in the group experience. An important nursing intervention will be to: a. Encourage the group to describe goals for change. b. Inquire whether the group needs more time to accomplish goals. c. Assist the group to explore alternative coping strategies for problems. d. Discuss feelings about leaving the group and the support found with the group.

D Healthy termination is facilitated when the group and nurse express reactions to termination. The nurse serves as a role model by being open and genuine as the feelings about the losses incurred with ending are discussed. On a positive note, accomplishments and growth are acknowledged and the transfer of safety and trust to the group members is accomplished. Describing goals is accomplished in the orientation phase. Accomplishing goals is part of the working phase in a relationship that does not have a strict time limit. Exploring alternative coping strategies would be part of the working stage. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Implementation

4. When a patients family asks why their chronically mentally ill adult child is being discharged to a community-based living facility, the nurse responds: a. It is a way to meet the need for social support. b. It is too expensive to keep stabilized patients in acute care settings. c. This type of facility will provide the specialized care that is needed. d. Being out in the community will help provide hope and purpose for living.

D Hospitalization may be necessary for acute care, but, when patients are stabilized, they move into community-based, patient-centered settings or are discharged home with continued outpatient treatment in the community. Concentrated efforts are made to reduce the patients sick role by providing opportunities for the development of a purposeful life and instilling hope for each patients future. Although social support is important, such a living arrangement is not the only way to achieve it. Although acute care is expensive, it is not the major concern when determining long-term care options. Community-based facilities are not the only option for specialized care. DIF: Cognitive Level: Application REF: Page 5 TOP: Nursing Process: Implementation

18. During a nursing assessment, a teenage patient smiles and states, I dont care what you say. I want to be just like Mike, the leader of our gang. The nurse understands the defense mechanism being used is: a. Denial b. Humor c. Splitting d. Identification

D Identification is wishing or trying to be like someone else. Denial is an unconscious refusal to acknowledge some reality. Humor is not being used. Splitting is viewing oneself and others as all bad or all good. DIF: Cognitive Level: Comprehension REF: Page 188 TOP: Nursing Process: Assessment

11. Which intervention has priority when a nurse suspects a staff member of providing patient care while being impaired by alcohol or drugs? a. Asking the staff member to explain their suspicious behavior b. Adjust the staff members assignment to minimize patient contact c. Providing the staff member with material regarding alcohol abuse and treatment d. Reporting the staff members suspicious behavior to the nursing supervisor on duty

D It is a professional obligation to report suspected impaired practice. The remaining options do not have prior in this situation since the concern is patient safety. DIF: Cognitive Level: Analysis REF: Page 332 TOP: Nursing Process: Diagnosis

: Pharmacological and Parenteral Therapies 8. Which of these statements made by a patient taking the MAOI phenelzine (Nardil) would warrant further instruction? a. I often forget to wear sunscreen when I go outside. b. I need to restrict the amount of sodium in my diet. c. I should not use over-the-counter cold medications. d. I usually order liver and onions when my wife and I eat out.

D MAOIs require patients to observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine. The remaining options have no relevance for MAOI therapy. DIF: Cognitive Level: Application REF: Page 580 TOP: Nursing Process: Evaluation

13. After the nurse discovered a medication error had been made, the patient was carefully observed and effectively treated for symptoms of a headache. What element of malpractice is most critical in determining the nurses liability? a. The nurse owed a legal duty to the patient. b. The nurse breached the recognized duty. c. The patient suffered harm as a result of the act. d. The harm was a direct result of the nursing act.

D Malpractice cannot be established unless the nurses action was the direct cause of the observed injury. A headache is not generally seen as an outcome of such a medication error. The remaining options reflect elements that are already recognized as being true. DIF: Cognitive Level: Application REF: Page 178 TOP: Nursing Process: Evaluation

17. A patient diagnosed with cancer of the prostate was admitted after his wife reported he was trying to mix a lethal dose of medications and alcohol to drink. Which patient outcome is a priority to this situation? a. Patient will participate in all unit activities. b. Patient will recognize that depression is treatable. c. Patient will learn ways to handle his unresolved anger. d. Patient will admit to suicidal thoughts when asked by staff.

D Notifying staff of suicidal ideations has priority since it is directly related to the patients safety. The other options lack the direct relationship to patient safety. DIF: Cognitive Level: Application REF: Page 516 TOP: Nursing Process: Outcome Identification

11. Which statement made by a patient who attempted suicide 5 days ago would cause the nurse to observe his behavior more closely? a. When Im discharged, maybe my son will let me stay with him. b. Im not sure I will ever really enjoy the things we did before I lost her. c. It puzzles me that anyone would want to kill themselves but I certainly did. d. My wife and I would have celebrated our thirty-sixth wedding anniversary today.

D Significant anniversary dates may be a time for future suicide attempts. The remaining options do not have the same level of risk since they are not expressing despair or indicate an available means. DIF: Cognitive Level: Application REF: Page 509 TOP: Nursing Process: Assessment

4. A student nurse mutters that it seems entirely unnecessary to have to struggle with understanding the anatomy and physiology of the neurologic system. The mentor would base a response on the understanding that it is: a. Necessary but generally for psychiatric nurses who focus primarily on behavioral interventions b. A complex undertaking that advance practice psychiatric nurses frequently use in their practice c. Important primarily for the nursing assessment of patients with brain traumacaused cognitive symptoms d. Necessary for planning psychiatric care for all patients especially those experiencing psychiatric disorders

D Nurses must understand that many symptoms of psychiatric disorders have a neurologic basis, although the symptoms are manifested behaviorally. This understanding facilitates effective care planning. The foundation of knowledge is not used exclusively by advanced practice psychiatric nurses nor is it relevant for only behavior therapies or brain trauma since dealing with the results of normal and abnormal brain function is a responsibility of all nurses providing all types of care to the psychiatric patient. DIF: Cognitive Level: Comprehension REF: Page 98 TOP: Nursing Process: Planning

14. A patient asks the nurse manager to help resolve a situation between her and another patient. Which action would best support the patients feelings of safety when experimenting with new ways of being? a. Encouraging the patient to report the incident to the other patients physician b. Intervening on the patients behalf and sorting out the incident with the other patient c. Suggesting that the patient ignore the situation since the other patient was probably not aware of her behavior d. Offering to be present and help the patient discusses her feelings about the incident with the other patient

D Offering to be with the patient affords her a safe nonthreatening opportunity to assume responsibility for meeting her own needs assertively by encouraging skills that affect positive communication. Intervening removes the responsibility from the patient. Ignoring supports passive behavior. There is no need to bring in another person. The patient is capable of addressing the problem herself. DIF: Cognitive Level: Application REF: Page 605 TOP: Nursing Process: Implementation

17. The patient and the nurse have agreed on problems to be addressed during a short course of outpatient therapy. At the beginning of the appointment, the patient states, Id like to work on the issue of relationships today. Which assessment can be made? a. Nurse-patient roles have not been clearly delineated. b. The nurse should suggest several alternative behaviors. c. The patient must be able to manage emotions before continuing. d. The relationship is moving from orientation to working phase.

D Once the patient and nurse have collaborated to define and prioritize problems, the relationship moves from orientation to working phase. The remaining options have no relevance to the scenario since there is no reference to roles, alternative behaviors, or managing behaviors. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Assessment

1. A patient with depression mentions to the nurse, My mother says depression is a chemical disorder. What does she mean? The nurses response is based on the theory that depression primarily involves which of the following neurotransmitters? a. Cortisol and GABA b. COMT and glutamate c. Monamine and glycine d. Serotonin and norepinephrine

D One possible cause of depression is thought to involve one or more neurotransmitters. Serotonin and norepinephrine have been found to be important in the regulation of depression. There is no research to support that the other options play a significant role in the development of depression. DIF: Cognitive Level: Comprehension REF: Page 104 TOP: Nursing Process: Assessment

: Pharmacological and Parenteral Therapies 33. An atypical antipsychotic has been prescribed for an elderly patient. The nurse developing the patients care plan includes: a. Scheduling weekly WBC counts b. Teaching about a tyramine-free diet c. Requesting that a daily laxative be included d. Teaching fall prevention strategies to both the patient and family

D Orthostatic hypotension is a possible side effect due to alpha-adrenergic blockade. The nurse should teach the patient about changing position slowly and using handrails when walking to prevent falls. The remaining options are not related to antipsychotic medications. DIF: Cognitive Level: Application REF: Page 571 TOP: Nursing Process: Planning

; Psychological Integrity 21. A well-stated outcome criteria for a patient with a nursing diagnosis of risk for loneliness related to social isolation would include The patient will: a. No longer experience loneliness by the end of the fifth day of hospitalization. b. Agree to attend two on-unit, staff-directed group sessions daily. c. Continue to maintain social solitude 50% of the time. d. Interact with a peer on a daily basis by discharge.

D Outcome criteria for a risk diagnosis are developed from the risk factorsin this case, social isolation. Outcomes meet criteria when they are measurable, specific, and present a timeline for completion. The correct option meets all criteria. There is no stated means by which to measure loneliness. Agreeing to attend is not specifically directed at affecting social isolation since interaction is not an expectation. Social solitude promotes social isolation. DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: Planning

: Physiological Adaptation 12. The daughter of an older patient with dementia tearfully tells the nurse that she doesnt know whats wrong with her mother, who has begun accusing the family of holding her prisoner. Which nursing diagnosis would be appropriate for this patient? a. Powerlessness b. Defensive coping c. Ineffective coping d. Disturbed thought processes

D Paranoid thinking is common in patients with dementia. Inability to correctly interpret environmental clues and to think logically leads to delusional thinking as the patient tries to make sense of a confusing world. The remaining options are not supported by the data in the scenario. DIF: Cognitive Level: Comprehension REF: Page 382 TOP: Nursing Process: Diagnosis

20. Which principle of recovery is the basis of the nurses response when a patient relapses and is hospitalized for alcohol detox treatment? a. Alcoholism requires a lifelong commitment to control. b. Most people who are serious about treatment achieve sobriety. c. Relapsing is an expected occurrence for the patient diagnosed with alcohol abuse. d. Rehabilitation generally involves several relapses before true sobriety is achieved.

D Sobriety is the goal of complete abstention from drugs, alcohol, and addictive behaviors. Sobriety often involves several attempts, and many patients relapse 9 or 10 times before achieving and sustaining sobriety. This information is the basis for the physical and emotional support provided by the nurse. Although citing that a relapse is not a failure but an expected part of the recovery process, this option does not include the needed information of the frequency of the possible relapses. The remaining options are not focused on relapsing. DIF: Cognitive Level: Application REF: Page 345 TOP: Nursing Process: Planning

16. A 34-year-old male admitted with catatonic schizophrenia has been mute and motionless for several days while at home prior to admission. He still appears stuporous in the hospital. Which nursing intervention would be an initial priority? a. Orienting the patient to the unit b. Reinforcing reality with the patient c. Establishing a nonthreatening relationship d. Assessing the patient for physical problems

D Patients who are mute and motionless and inattentive to environmental stimuli are at risk for a number of physical problems. Further, they are unable to communicate existing problems. The nurse must make thorough and astute assessments before creating plans to meet the patients needs. A patient who is stuporous may not be able to attend to information given about unit rules and protocols. While establishing a therapeutic nurse-patient relationship is an important intervention, it does not have priority according to Maslows hierarchy. Because the patient is mute, one can only suspect lack of reality orientation. While an appropriate intervention, it is not the priority according to Maslows hierarchy. DIF: Cognitive Level: Application REF: Page 275 TOP: Nursing Process: Implementation

4. When planning care for a patient with antisocial personality disorder, which consideration has greatest importance? a. Addressing the demand for constant attention b. Teaching coping skills related to frustration tolerance c. Identifying behaviors related to well-developed superegos d. Managing the manipulative behaviors resulting from a charming persona

D Patients with antisocial personality disorder are described as charming because of their ability to size up and manipulate others. Narcissistic patients demand constant attention. Patients with histrionicpersonality disorder do not tolerate delay of gratification or frustration. Patients with personality disorder have poorly developed superegos. DIF: Cognitive Level: Application REF: Page 306 TOP: Nursing Process: Planning

38. Which activity would be a constructive outlet for tension and anxiety while enhancing self-esteem for a patient with adjustment disorder with anxious mood? a. Knitting scarves for a homeless shelter b. Painting a paint-by-number scenic picture c. Working on a large, colorful picture puzzle d. Engaging in regular, age-appropriate physical exercise

D Physical exercise may assist in relieving tension and promoting feelings of well-being. Knitting is tedious and requires steadiness, which the patient may not have if symptoms of anxiety include jitteriness. Painting requires fine motor coordination, not always present if a patient is anxious. Some patients find puzzles frustrating and become even more tense while working on one. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Planning

6. When communicating with a psychotic, schizophrenic patient, the nurse avoids the use of slang phrases most importantly because: a. Such phrases have different meanings for different people. b. Such phrases will likely trigger anxiety and frustration in the patient. c. The use of such phrases is not appropriate when communicating therapeutically with a patient. d. This patients altered thought processes will serve to make understanding such phrases very unlikely.

D Precise verbal communication is important because spoken words often mean different things to different people. Figures of speech, jokes, clichs, colloquialisms, and other terms or special phrases carry a variety of meanings especially to individuals with altered thought processes. A person with schizophrenia interprets concretely and literally whereas psychosis generally brings about loose associations. Although all the options are reasons to avoid the use of slang phrases, the primary reason in this case in to avoid confusing the patient. DIF: Cognitive Level: Analysis REF: Page 64 TOP: Nursing Process: Planning (Communication and Documentation)

34. A patient with schizophrenia is medication compliant and has well-controlled symptoms. He has, however, never been successful in holding a job because of poor social skills and lack of understanding of basic job skills. The nurse case manager should consider referring the patient: a. For cognitive therapy b. To assertiveness training c. To a day hospital program d. For psychosocial rehabilitation

D Psychosocial rehabilitation helps patients readjust to community living by promoting development of necessary skills. Social skills training and job skills training programs are usually available. The patient does not need the more intensive services found in a day hospital. Cognitive therapy will not offer the needed community living skills training. Assertiveness training is only a small portion of the community living skills the patient needs. DIF: Cognitive Level: Application REF: Page 288 TOP: Nursing Process: Planning

34. Which of the following would be an appropriate outcome for a patient diagnosed with rape-trauma syndrome? a. Patient will sleep 8 hours without medication by week 6 of therapy. b. Patient will develop better self-esteem by week 8 of therapy. c. Patient will accept nurses word that her reactions are normal. d. Patient will verbalize that recovery may never happen totally.

D Rape trauma victims require time to process what has happened to them and to reorganize their lives, just as an individual who is grieving must do. The remaining options are not realistic nor therapeutic. DIF: Cognitive Level: Application REF: Page 550 TOP: Nursing Process: Outcome Identification

: Pharmacological and Parenteral Therapies 35. When following up on SSRI medication side effects, the nurse will need to make specific inquiries about: a. Anticholinergic symptoms b. Alpha-adrenergic blockade c. GI tract symptoms d. Sexual dysfunction

D SSRIs often cause sexual dysfunction, a symptom patients may be reluctant to bring up voluntarily. Patients readily bring up the side effects mentioned in the other options. DIF: Cognitive Level: Application REF: Page 578 TOP: Nursing Process: Implementation

30. A patient is exhibiting auditory hallucinations in addition to being forgetful and easily confused. Which diagnosis does the nurse base this patients interventions on? a. Social isolation b. Deficient knowledge c. Situational low self-esteem d. Impaired cognitive functioning

D Schizophrenia may alter cognitive functioning, including memory, retention, attention, and the processing of incoming information. Altered cognition accounts for many of the symptoms mentioned in the scenario. Knowing that cognition is altered, the nurse can adjust plans to take the deficits into account. The patient is not exhibiting symptoms that would warrant any of the other options. DIF: Cognitive Level: Application REF: Page 263 TOP: Nursing Process: Planning

3. What is the priority nursing diagnosis for a catatonic patient? a. Ineffective coping b. Impaired physical mobility c. Impaired social interaction d. Risk for deficient fluid volume

D The highest priority for the patient is maintenance of basic physiologic needs, such as hydration. Mobility is of lesser physiological importance than fluid volume. The remaining options do not have priority over a physiological need. DIF: Cognitive Level: Application REF: Page 275 TOP: Nursing Process: Diagnosis

13. Which assessment demonstrates the nurses understanding of the relationship between substance abuse and the development of symptoms characteristic of delirium? a. Determining the patients age and gender b. Evaluating the patients food and fluid intake over the last 48 hours c. Observing the patient for fine tremors of the hands, especially the fingers d. Determining the amount of caffeine the patient ingested in the last 24 hours

D Some people who ingest large amounts of caffeine develop delirium. The remaining options are not relevant to caffeine ingestion or the abuse of any other substance. DIF: Cognitive Level: Analysis REF: Page 340 TOP: Nursing Process: Assessment

7. The nurse is considering the need for both effective means of communication and safety when caring for a patient with impulse control issues and poor social skills. Which nursing intervention is most appropriate to address these needs? a. Reminding the patient with each interaction what space boundaries are considered safe and desired b. Asking the patient to describe and set space boundaries that feel safe and facilitate effective communication c. Clearly setting space boundaries for the patient so both patient and staff feel safe and can communicate more effectively d. Discussing the need for space boundaries and how they help both the patient and the staff feel safe and aide in communicating effectively

D Space as a concept of boundaries and safety is important to understand because the nurse and the patient need to respect the distance that each needs. For successful communication to occur, both parties need to feel safe. Some patients have problems with their boundaries and invade other patients own safe zones; patients who perceive this as threatening react aggressively to such boundary violations. The nurse may need to help the patient understand the need for appropriate distances in order for everyone to feel safe and to communicate effectively. Reminding the patient of what the boundaries are without first discussing the importance of space boundaries is not an effective technique. Having the patient set the boundaries does not take into consideration the needs of others, whereas staff setting the boundaries without patient involvement ignores the needs of the patient and prevents the patient from understanding of the situation. DIF: Cognitive Level: Application REF: Page 65 TOP: Nursing Process: Planning (Communication and Documentation)

10. The nurse is considering making a child abuse or neglect report to protective services. To make the report, the nurse needs to: a. Have strong evidence that the abuse/neglect has occurred. b. Obtain the supervisors permission to make the report. c. Notify the parents of the intent to file the report. d. Have suspicions that the abuse has occurred.

D Suspicions are all that are required by state mandatory child abuse and neglect reporting laws. The agency bears the burden of collecting evidence. As a mandated reporter, the nurse does not need anyones permission to make the report. Only a suspicion is required. Parent notification is unnecessary. DIF: Cognitive Level: Application REF: Pages 540-541 TOP: Nursing Process: Planning

2. The nurse is to perform a complete assessment of a patient in her home, using the Mini-Mental State Examination (MMSE) as one component. When the nurse arrives, the patient is seated at the table with her husband, the TV is on, and several grandchildren are visiting. The patient is quiet, but her hands are gripped tightly, and she is staring at the ceiling. The best action for the nurse to take would be which of the following? a. Ask the husband to make an appointment to bring his wife to the clinic for testing. b. Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room. c. Do not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family. d. Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.

D Testing the patient in her home under quieter, less distracting circumstances is the best solution. Asking the husband to leave is likely to increase the patients anxiety and alter test results. Use of the MMSE is an integral component of the assessment and must not be deleted. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results. DIF: Cognitive Level: Application REF: Page 378 TOP: Nursing Process: Implementation

21. Which assessment observation is the best support for a patients diagnosis of alcoholism? a. Reporting, I messed up three marriages. b. Testing positive for hepatitis B virus (HBV) c. Admission that, I drink more than I should. d. A positive response to three items on the CAGE test

D The CAGE questionnaire is a well-validated screening instrument. A positive response to two of the four items of the CAGE questionnaire indicates a potential problem with alcoholism. Although the remaining options are recognized red flags for possible alcoholism, they lack the selectivity of the screening tool. DIF: Cognitive Level: Analysis REF: Page 347 TOP: Nursing Process: Assessment

29. Which statement regarding the various types of child offender is correct? a. The physical offender lacks remorse, although the sexual offender usually shows guilt and shame. b. The physical offender has diverse characteristics, although the sexual offender has lack of remorse. c. The physical offender has a mature ego, although the sexual offender has a rigid, overdeveloped superego. d. The physical offender has poor self-esteem and unrealistic expectations of children, although the sexual offender has diverse characteristics.

D The child physical offender often is assessed as having poor self-esteem, poor impulse control, unrealistic expectations of children, immaturity, and minimal external supports. The child sexual offender has diverse characteristics, with no profile becoming apparent. The child sexual offender often does not show remorse for the acts. DIF: Cognitive Level: Application REF: Pages 536-537 TOP: Nursing Process: Assessment

23. When assigning the suicidal patient to a room on the unit, the nurse should select a: a. Single room near the exit b. Double room near the exit c. Single room near the nurses station d. Double room near the nurses station

D The correct option implements the helpful practice if having a roommate for the suicidal patient and observation of the patient is easier if the room is close to the nurses station. The remaining options lack both of those interventions. DIF: Cognitive Level: Application REF: Page 517 TOP: Nursing Process: Implementation

5. Which social factor has the greatest impact on the changing nature of alcohol abuse treatment? a. Development of new pharmaceutical treatment options b. Dramatic increase of alcoholism among young adult males c. Raising cost of both inpatient and outpatient treatment programs d. Womens substance abuse only recently acknowledge by society

D The existence of an alcohol abuse problem among women has only been recently recognized and this has dramatically affected treatments and services being provided. Although the other options are true, they do not have the impact on treatment modalities as much as the correct option. DIF: Cognitive Level: Application REF: Page 330 TOP: Nursing Process: Assessment

: Chemical and Other Dependencies 9. When a patient experiencing acute depression asks what the difference is between a medical and a nursing diagnosis, the nurse responds best when stating: a. Actually they are very similar in that they both are concerned with helping you get better and lead a happier life. b. Medical diagnoses are focused on why you are depressed whereas nursing diagnoses are concerned about making your life less sad. c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses that focus on finding the cause for your problem. d. The medical diagnosis identifies that you are experiencing depression whereas the nursing diagnosis identifies how the depression is affecting you.

D The medical diagnosis involves identifying a mental or physical problem that results in the symptoms that negatively affect a patients life. Although the nurse is knowledgeable about the disorders and their treatments, the nursing diagnosis focuses mainly on the patients responses to the disorder and the effects that the disorder has on the patient. The types of diagnoses have different foci that result in different actions and concerns. DIF: Cognitive Level: Application REF: Page 49 TOP: Nursing Process: Implementation (Teaching and Learning)

17. Which principle should the nurse apply when planning care for a patient who is diagnosed with bipolar disorder and currently in the manic phase? a. Manic patients respond well to peer pressure. b. Decreasing stimulation tends to diminish symptoms. c. Increasing stimulation tends to encourage the patient to focus. d. Detailed activities will facilitate the patients ability to self control behavior.

D The only statement that is a valid principle is the option related to activity and its impact on controlling behavior. The other statements are inaccurate. DIF: Cognitive Level: Application REF: Page 246 TOP: Nursing Process: Planning

; Physiological Integrity 6. A patient who has a parietal lobe injury is being evaluated for psychiatric rehabilitation needs. Of the aspects of functioning listed, which will the nurse identify as a focus of nursing intervention? a. Expression of emotion b. Detecting auditory stimuli c. Receiving visual images d. Processing associations

D The parietal lobe is responsible for associating and processing sensory information that allows for functions such as following directions on a map, reading a clock, dressing self, keeping appointments, and distinguishing right from left. Emotional expression is associated with frontal lobe function. Detecting auditory stimuli is a temporal lobe function. Receiving visual images is related to occipital lobe function. DIF: Cognitive Level: Application REF: Page 101 TOP: Nursing Process: Planning

37. Immediately after electroconvulsive therapy (ECT), nursing care of the patient is most similar to care of a patient: a. With severe dementia b. With delirium tremens c. Recovering from conscious sedation d. Recovering from general anesthesia

D The patient who has ECT receives a short-acting IV anesthetic and a skeletal muscle relaxant. Thus care is most similar to the patient recovering from general anesthesia. The nurse will assess vital signs, quality of respirations, presence or absence of the gag reflex, level of consciousness, orientation, and motor abilities during the post-treatment period. DIF: Cognitive Level: Application REF: Page 620 TOP: Nursing Process: Implementation

: Pharmacological and Parenteral Therapies 1. Which intervention best reflects the nursing role regarding effective implementation of behavioral therapy goals? a. Administering the prescribed medications accurately b. Interacting effectively with members of the health care team c. Being aware of all the patient related therapeutic modalities d. Evaluating patient behaviors to reward economic tokens appropriately

D The primary role of the nurse who is involved in behavioral therapy is to assess and identify the patients problem behaviors in collaboration with the multidisciplinary team. A token economy is a system of behavior reinforcements in which patients earn tokens by performing predetermined desired behaviors. The remaining options are generalized responsibilities that are relevant to any therapy format. DIF: Cognitive Level: Application REF: Page 600 TOP: Nursing Process: Implementation

18. The nurse conducts milieu therapy based on the understanding that: a. Therapy is grounded in the milieu routine. b. The milieu is a substitute for the patients family. c. Staff represents the authority within the milieu. d. The milieu provides realistic community interactions.

D The purpose of milieu therapy is to recreate a community setting on these units so that the patient is able to interact with other patient peers to identify and problem-solve issues that occur when relating to others. The milieu does not replace the patients family. The remaining options are not true. DIF: Cognitive Level: Application REF: Page 315 TOP: Nursing Process: Implementation

11. The nurse is working with a patient with an anxiety disorder whose treatment includes cognitive behavioral therapy. Which statement by the patient gives the nurse reason to assume that the patient has an understanding of the basis of this type of therapy? a. My abusive childhood has resulted in my overreaction to stress. b. My delusional thoughts of extreme anxiety are what cause my panic attacks. c. My brain chemistry causes me to overreact to common stress by getting so anxious. d. Ive learned to react to my daily stress by having anxious thoughts and panic attacks.

D The success of this approach centers on the patients understanding that the symptoms are a learned response to thoughts or feelings about behaviors that occur in daily life. Cognitive therapy helps patients identify target symptoms and change the cognitions associated with them. This is a psychodynamic model explanation. Anxiety disorders have no relationship to delusions. Brain chemistry is not a usual cause of anxiety but rather can be altered by anxiety. DIF: Cognitive Level: Application REF: Page 201 TOP: Nursing Process: Evaluation

10. Mental health care reform has called for parity between psychiatric and medical diagnoses. Which is an example of such parity? a. Depression treatment is not paid for as readily as is treatment for asthma. b. The mentally ill patient will be protected by law against social stigma. c. Medical practitioners are trained to be proficient at treating mental disorders. d. Psychiatric service reimbursement will be equivalent to that of medical services.

D The term parity as used here refers to payments for mental health services that equal payment schedules for medical or surgical conditions. The remaining options(B and C) do not relate to financial reimbursement or funds allocated for mental health care being equal to those of medical diagnoses. DIF: Cognitive Level: Application REF: Page 15 TOP: Nursing Process: Implementation

35. A patient prescribed an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should: a. Administer the medication and monitor the vital signs every 4 hours. b. Give a lower dose of the medication for 24 hours and monitor the blood pressure. c. Prepare to administer a prn dose of the anticholinergic drug benztropine (Cogentin). d. Hold the medication and immediately describe the patients symptoms to the doctor.

D These symptoms could be related to a possibly fatal disorder called neuroleptic malignant syndrome (NMS), and the nurse should hold the medication and contact the doctor immediately. The other options are inappropriate in light of the seriousness of the situation. DIF: Cognitive Level: Analysis REF: Page 289 TOP: Nursing Process: Assessment

12. The nurse caring for an extremely withdrawn patient with depression wants to assist her to become more interactive. The best approach would be to say: a. I know youll feel better if you leave your room. b. You look so gloomy sitting here all by yourself. c. Lets explore how it feels to sit alone here all day and feel sad. d. I need another person for a card game and Id like you to be my partner.

D This direct approach invites the patient to participate in a kind, but firm manner. The patient is not given an option to simply say yes or no. It is not therapeutic to give false reassurance. The remaining options focus too intensively on negative thoughts and feelings. DIF: Cognitive Level: Application REF: Page 245 TOP: Nursing Process: Implementation

8. A patient admitted for treatment of symptoms related to paranoid schizophrenia refuses to sign a consent form allowing the nurse to discuss any aspect of his hospitalization with his parents. Which statement by the nurse best respects the patients rights while providing effective care? a. Reminding the parents that, I cant discuss your son even though I want to. b. Asking the patient to, please talk with me about why you dont trust your parents? c. Telling the patient that, Keeping your parents uninvolved in your care is very painful for them. d. Telling the parents that, While I cant discuss his care with you, you can tell me anything you think I need to know.

D This option provides the family the ability to communicate important medical or behavioral history to the treatment facility without the nurse releasing any information about the patient without that patients permission. It is inappropriate for the nurse to express such personal feelings about the patients wishes. Challenging the patients decision in these manners does not fulfill the nurses role as advocate. DIF: Cognitive Level: Application REF: Page 171 TOP: Nursing Process: Implementation

12. In response to the nurses statement, Tell me about your family, the patient became silent and displayed nonverbally that he is uncomfortable. Which statement by the nurse reflects sensitivity to the patient? a. Im so sorry. I didnt realize your family was a problem for you. b. Learning to express negative feelings will assist you in getting well. c. Perhaps you can talk about your feelings to the physician next time you meet. d. That seems to be a difficult subject for you. We can discuss when you are ready.

D This response acknowledges the situation, is respectful, and allows the patient to choose when to refocus the therapeutic interaction. Referring to the family as a problem is not sensitively worded. Offering false reassurance implies that feelings are negative. Suggesting postponing the discussion represents avoidance of dealing with the patients feelings. DIF: Cognitive Level: Application REF: Page 605 TOP: Nursing Process: Implementation

20. During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, Why are you bothering to ask the rest of us questions? My son is the one with the problems. The best response for the nurse would be: a. Well get more accurate information if the entire family is involved. b. It may seem strange to you, but well get better results doing it this way. c. When one family member is sick, the whole family system is sick as well. d. Every family members perceptions are very important to the total picture.

D This response orients the family to the idea that each persons opinion will be valued. Having the family present for assessment prepares them for working together to identify family issues, identify outcomes, and solve problems. It may or may not be true that this will result in accurate information. Getting better results doesnt convey the real reason. Referring to the family as sick is pessimistic and conveys a threatening message. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Implementation

3. The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patients life processes when stating in the patients plan of care that: a. Patient outcomes were partially attained. Implementation of present plan to continue. b. Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future). c. Oral medication for anxiety should be administered when depression is assessed to be at the moderate level. d. Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses.

D This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning. DIF: Cognitive Level: Application REF: Pages 47-48 TOP: Nursing Process: Analysis

11. Which statement by a 16-year-old is considered as positive evidence that the familys involvement in therapy is moving them towards effective functioning? a. My dad has finally stopped giving me advice on how to live my life. b. I stopped playing football since practice required me to be away from home so often. c. Since my mother quit her job, she is more available to keep the home running smoothly. d. Eating dinner with my parents on Sunday nights has helped us be more aware of each others needs.

D This statement shows the family has made an effort to improve communication and deal with alienation without any one member bearing complete responsibility. Withdrawing from the team suggests he felt solely responsible for the family problem. Quitting the job suggests the mother saw herself as responsible; however, being home does not guarantee unification. A lack of advisement suggests withdrawal of the father from participation in family matters. DIF: Cognitive Level: Application REF: Page 612 TOP: Nursing Process: Evaluation

2. A patient was placed in restraints for 2 hours in order to help manage impulsive, destructive, unsafe behavior. Which statement made by the charge nurse during a meeting to discuss the incident shows an understanding of the need to use restraints only as a last resort? a. How did this situation get so out of control? b. You all know that restraints are used only as a last resort. c. Can anyone tell me why restraints were used on this patient? d. Lets review what exactly happened that led to the use of restrains.

D To facilitate an open, honest review of the incident that will permit learning to take place, the charge nurse must not place the staff on the defensive. Reviewing the events leading up to the patient being restrained in a nonaccusatory manner shows an understanding of proper restraint use. The other options imply the nurse manager does not believe the situation was handled in an appropriate way. DIF: Cognitive Level: Application REF: Page 173 TOP: Nursing Process: Implementation

5. What is the best explanation to offer when the mother of a chronically ill teenage patient asks, Under what circumstances would he be considered incompetent? a. When you can provide the court with enough evidence to show that he is not able to care for himself safely. b. It is not likely that someone his age would be determined to be incompetent regardless of his mental condition. c. He would have to engage in behavior that would result in harm to himself or to someone else; like you or his siblings. d. If the illness becomes so severe that his judgment is impaired to the point where the decisions he makes are harmful to himself or to others.

D When a person is unable to cognitively process information or to make decisions about his or her own welfare, the person may be determined to be mentally incompetent. Providing self-care is not the only criteria considered. Age is not a factor considered. The decision is often based on the potential for such behavior. DIF: Cognitive Level: Application REF: Page 6 TOP: Nursing Process: Implementation

22. The nurse is interviewing a patient who presents with a dislocated shoulder and demonstrates signs of anxiety although relying on her partner for answers. Although the partner is out of the room, which question is most important to ask? a. Have you been with your partner long? b. Are you being abused by your partner? c. Shall I notify the police that you would like to press charges? d. Have you ever been physically or emotionally hurt by someone?

D When the victim is alone, the nurse must seek information about abuse. Phrasing the question to avoid use of such terms as abuse or battered is essential. These terms are too emotionally charged, and patients often respond in the negative. The length of the relationship is not a priority. Asking to call the police is premature. DIF: Cognitive Level: Application REF: Page 531 TOP: Nursing Process: Assessment