Exam 4
In order to be admitted to an inpatient treatment program, clients with anorexia nervosa must meet the admission criterion of having experienced at least a 30% weight loss over the immediate past 6 months. The client currently weighs 84 pounds. The nurse calculates that 6 months ago, this client weight at least __________ pounds. Record your number rounding to a whole number.
120
A client reports episodic depersonalization experiences to the nurse. Which of the following would be an appropriate goal of care? a. the client will describe 3 stress management techniques by day 2 b. the client will report no suicidal thoughts by week 1 c. the client will create a chart of all personalities by week 1 d. the client will state 5 personal strengths by day 2
a
A nursing assistant (NA) asks for advice about talking with a client recently diagnosed with dissociative identity disorder (DID). What would be the nurse's best response when the NA says, "Should I talk about her childhood abuse?" a. "If she brings up the abuse, listen to her and be supportive." b. "You will need to really push her to get it all out." c. "Ask her to discuss this only with her therapist." d. "Remind her that sometimes adults exaggerate their childhood experiences."
a
How should the nurse respond to a mental healthcare worker who asks about the best way to work with a client diagnosed with schizophrenia with paranoid behavior? a. "When possible, remain at arm's length from the client." b. "The client is anxious. Offer back rubs at bedtime." c. "Offer the client a hand-shake before beginning a conversation." d. "To get the client's attention, place your hand gently on the arm or hand."
a
The nurse employs play therapy with a small group of 6 year old clients. The primary expected outcome is for the clients to do which of the following? a. act out feelings in a constructive manner b. learn to talk openly about themselves c. learn how to give and receive feedback d. learn problem solving skills
a
The nurse should prioritize which nursing intervention for a client recently admitted to an inpatient unit with a dissociative disorder? a. creation of a calm, safe environment b. increasing sensory stimulation c. working through past trauma d. promoting social skills
a
The spouse of a client who is experiencing a fugue state asks the nurse if the spouse will be able to remember what happened during the time of the fugue. What is the nurse's best response? a. "Your spouse will probably have no memory of events during the fugue." b. "Your spouse will be able to tell you, if you can gently encourage talking." c. "It is not possible to predict whether your spouse will remember the fugue state." d. "Avoid mentioning it, or your spouse may start alternating old and new identities."
a
What short term goal should the nurse formulate as an appropriate goal for a hospitalized client who is severely withdrawn? a. attend one group meeting accompanied by a staff member within 3 days b. voluntarily lead the unit community meeting by the time of discharge from the hospital c. be more comfortable in group situations within 3 days d. enjoy participating in group therapy by the time of discharge
a
What term should the nurse use to document a client who is taking antipsychotic meds, pacing the hallway, unable to remain still, and reports feeling nervous? a. akathisia b. akinesia c. dystonia d. tardive dyskinesia
a
Which primary interventions should the nurse plan for when a child has conduct disorder and is impulsive and aggressive? a. limit setting and consistency b. open communication and a flexible approach c. open expression of feelings d. assertiveness training
a
ideas of reference
a cognitive distortion in which an individual believes that what is in the environment is related to him or her, even when no obvious relationship exists; also called personalization
psychosis
a disorderly mental state in which a client has difficulty distinguishing reality from his or her own internal perceptions
delusional ideation
a false belief brought about without appropriate external stimulation and inconsistent with the individual's own knowledge and experience
derealization
a feeling that the external world is unreal or strange
echopraxia
a meaningless imitation of motions made by others
milieu therapy
a method of psychotherapy that controls the environment of the client to provide interpersonal contacts in order to develop trust, assurance, and personal autonomy
The school nurse is conducting an assessment to determine if a client has anorexia nervosa. Which statement(s) by the client will most suggest that the client may have this disorder? (select all that apply) a. "I don't have periods anymore. I'm glad." b. "People say I'm skinny, but I'm fat and repulsive." c. "I want to be a chef and cook for other people." d. "The idea of eating makes me nauseated." e. "I know that I have a problem with eating."
a, b, c, d
Which manifestations should the nurse anticipate in a client who is diagnosed with schizophrenia and demonstrates catatonic behavior? (select all that apply) a. rigidity b. waxy flexibility c. paresthesia d. extreme psychomotor retardation e. high BP
a, b, d
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antispychotics? (select all that apply) a. auditory hallucinations b. withdrawal from social situations c. delusions of grandeur d. severe agitation e. anhedonia
a, c, d
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (select all that apply) a. "When did you start hearing these things?" b. "The voices are not real, or else we would both hear them." c. "It must be scary to hear voices." d. "Are the voices you hear telling you to hurt yourself?" e. "Why are the voices talking to only you?"
a, c, d
A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss a change to which of the following medications? (select all that apply) a. olanzapine b. quetiapine c. aripiprazole d. clozapine e. asenapine
a, c, d, e
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (select all that apply) a. auditory hallucinations b. lack of motivation c. use of clang associations d. delusion of persecution e. constantly waving arms f. flat affect
a, c, d, e
The nurse is conducting a community education session about preventing deaths in adolescents with depression. Which of the following might be considered indicators of depression in adolescents? (select all that apply) a. decreased flexibility of affect (flattened affect) b. excessive washing of hands c. hypersomnia d. AIDS e. difficulties at school
a, c, e
The nurse assessing a client with dissociative identity disorder (DID) expects to note which of the following manifestations? (select all that apply) a. hx of headaches b. elated mood c. intact memory for recent and remote events d. asthma e. irritable bowel syndrome
a, d, e
The nurse should select which nursing concerns as appropriate priorities for a client experiencing a fugue state? (select all that apply) a. anxiety b. impaired self esteem c. disruption of family processes d. relocation-related stress e. PTSD
a, e
anorexia nervosa
an eating disorder in which an individual attempts to lose weight by dramatically decreasing food intake and increasing physical exercise
illusion
an inaccurate perception or misinterpretation of sensory impressions
echolalia
an involuntary parrotlike repetition of words spoken by others
A 13 year old child is brought to the clinic with a history of conduct disorder. The nursing history reveals several facts about the family. Which parent-related factor is most likely to have contributed to the child's conduct problems? a. very high expectations of the child b. harsh discipline and inconsistent limit setting c. excessive involvement in the everyday life of the child d. having no other children
b
A client is brought to the ER after a brutal physical assault. Although oriented and coherent, the client cannot remember the assault or the events surrounding it. Which nursing intervention should be the priority of the nurse? a. frequent reality orientation b. physical comfort and safety c. thoughtful questioning for the police report d. referral to a community support group
b
A client with DID is admitted after an overdose of alcohol and benzodiazepines, claiming that "another alter did it." The nurse should formulate which of the following as the priority nursing concern? a. PTSD b. risk for violence inflicted on self c. personal identity disturbance d. anxiety
b
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? a. encourage the client to participate in group therapy on the unit b. initiate one-on-one observation of the client c. focus the client on reality d. notify the provider of the client's statement
b
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? a. "I am a superhero and am immortal." b. "I am no one, and everyone is me." c. "I feel monsters punching me all over." d. "I know that you are stealing my thoughts."
b
A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? a. stop the interview at this point, and resume later when the client is better able to concentrate b. ask the client, "Are you seeing something on the ceiling?" c. tell the client, "You seem to be looking at something on the ceiling. I see something there, too." d. continue the interview without comment on the client's behavior
b
The adolescent client is experiencing depression. The client's prescribed medication is fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do inside my brain?" a. "It will help you feel less depressed." b. "It will regulate a neurotransmitter called serotonin." c. "It will raise your level of the brain hormone norepinephrine." d. "It will balance BG and dopamine levels."
b
The client has DID. When the client is changing from one alter to another, which client manifestation should the nurse expect to assess? a. orthostatic hypotension b. blinking or rolling of the eyes c. dystonic rxns d. pallor
b
The client, although oriented to person, place, and time, cannot remember being extracted from a burning automobile the day before. What term should the nurse use when documenting the client's inability to remember events surrounding the accident? a. suppression b. localized amnesia c. confabulation d. continuous amnesia
b
The nurse has taught a client experiencing dissociative amnesia about therapeutic methods for memory retrieval. The nurse should determine that the instruction has been effective when the client makes which statement? a. "Even if it does uncover hidden memories, I don't want to have ECT." b. "I'm a little uneasy about being hypnotized, but it does help release memories." c. "If I use relaxation techniques properly, my memories will come back quickly." d. "Anxiety causes this memory problem, and antianxiety agents will greatly reduce it."
b
The nurse is caring for a 4 year old child. The elicit information about the child's feelings, the nurse offers the child a series of pictures showing facial expressions and asks the child to point to the picture that shows the child's own feelings. The nurse bases these actions on which developmental concept? a. Sullivan's concept of dynamism b. Piaget's concept of pre-operational thinking c. Freud's concept of mechanisms of the ego d. Erikson's concept of industry vs inferiority
b
The nurse is conducting an in-service education session about the relationship between anxiety and bulimia nervosa. The nurse best describes the relationship by stating: when a client has bulimia nervosa, an increase in the anxiety level will generally result in which of the following? a. rigidity controlling what he or she eats b. binging and purging c. overeating d. consuming alcohol
b
The nurse is evaluating the progress of an adolescent client with bulimia being treated as an outpatient. Which client behavior would indicate that the client is making positive progress? a. the client asks the nurse many details about the nutritional content of foods b. the client shows the nurse a completed food and emotion diary c. the client reports enjoying spending time alone after meals d. the client describes eating at times other than when family members eat
b
The nurse is teaching a group of young adolescents about eating disorders. The nurse would consider the sessions effective if the participant s state that anorexia nervosa is best defined as an eating disorder that occurs in which individuals? a. only in young girls who are depressed b. mainly in young girls who perceive themselves to be grossly overweight c. primarily in young girls who live in chaotic families d. in young boys and girls alike
b
The nurse observes that a client with schizophrenia appears very preoccupied. The client is pacing back and forth in the hall periodically looking to the side, clenching their fist, and saying, "I told you to go away." The nurse should plan to take which actions during client care? (select all that apply) a. offer frequent orienting stimuli b. reduce proximity to others c. refrain from using nonverbal hand gestures d. avoid touching the client during conversation e. reassure the client of the safety of the environment
b
The nurse should conclude that client education to manage dissociative episodes is effective if the client states to do which of the following if the client starts to dissociate? a. "Immediately take my antianxiety medication." b. "Focus on what I can see and hear externally." c. "Begin my relaxation technique." d. "Focus on my internal feelings."
b
What is the best response by the nurse to a client who reports blurred vision that began after beginning a traditional antipsychotic? a. "You need to schedule an appointment with your eye doctor to get a new prescription for your eyeglasses." b. "Blurred vision is a side effect of your medication that usually resolves within a few weeks." c. "You need to stop taking your antipsychotic medication and notify your healthcare provider immediately." d. "Blurred vision is a permanent condition as a result of your medication."
b
What is the most appropriate response by the nurse to a client diagnosed with schizophrenia who refuses to be weighed by a member of the nursing staff and says, "Everyone here is part of the secret police and wants to torture me"? a. "That is a strange idea. We aren't secret police." b. "That must be frightening thought. We are nurses who work at this hospital." c. "Being suspicious isn't easy, is it? You won't be tortured here." d. "There is no need to be frightened. We will keep you safe from torture."
b
What is the nurse's best response to a family member of a client diagnosed with schizophrenia who asks the nurse to explain what causes this disorder? a. "Research indicates that schizophrenia is caused by a genetic predisposition." b. "The exact cause of schizophrenia is unclear at this time." c. "It is likely that poor parenting skills cause schizophrenia to occur." d. "It is clear that early age psychological traumas cause schizophrenia."
b
When assessing an adolescent client for depression, it is most important for the nurse to recognize that depression in adolescents is often which of the following? a. similar in presentation to depression in adult clients b. masked by aggressive behaviors c. situational and not as serious as depression in adults d. an indication of family dysfunction
b
Which of the following is the highest priority intervention for the nurse who is working with a child with a phobia? a. have the child face his or her fear b. decrease fear and anxiety c. protect the child from fears d. allow the child to express fears
b
A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an EPS? (select all that apply) a. decreased LOC b. drooling c. involuntary arm mvts d. urinary retention e. continual pacing
b, c, e
When teaching a client about negative symptoms of schizophrenia, which symptoms should the nurse include? (select all that apply) a. abnormal thoughts b. diminished pleasure c. blunted affect d. hallucinations e. difficulty making decisions
b, c, e
A client is diagnosed with depersonalization/derealization disorder. Which client data is the nurse likely to gather during the assessment? (select all that apply) a. two or more personalities b. feelings like "being in a dream" c. indifference to the symptoms d. feeling like a robot e. amnesia about the event
b, d
Which statements by the family member of a client diagnosed with chornic schizophrenia should indicate to the nurse that the client is experiencing a reduction in negative symptoms? (select all that apply) a. "We walked together for 15 minutes, and I could see no evidence he was 'hearing voices.'" b. "For the past week, he has gotten up, dressed, and taken a walk early each morning." c. "It's been more than a month since he said that he is a Martian prince." d. "We went to a musical concert, and he smiled and applauded the musicians." e. "I've noticed that his thoughts are better organized."
b, d
A client diagnosed with schizophrenia says, "I want to go home to tome in a dome." When documenting, the nurse will refer to this as which of the following? a. echopraxia b. echolalia c. clang associations d. associative looseness
c
A client diagnosed with schizophrenia tells the nurse that another client is "creating negative thoughts in me against my will." The nurse documents that the client is exhibiting which of the following features of schizophrenia? a. thought broadcasting b. thought blocking c. thought insertion d. thought control
c
A client with DID suddenly begins to speak with a child's vocabulary and voice. The nurse should interpret this as which of the following? a. an attempt to gain attention b. a state of depersonalization c. changing to a child alter d. malingering
c
A client with DID suddenly has a change in voice quality and sentence structure. What is the most therapeutic response by the nurse? a. "You must be feeling very needy." b. "I wonder why you're not acting your age." c. "Can you tell me what is happening?" d. "This behavior keeps you from working on your problems."
c
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following meds? a. chlorpromazine b. thiothixene c. risperidone d. haloperidol
c
A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the teaching? a. "I will be able to stop taking this medication as soon as I feel better." b. "If I feel drowsy during the day, I will stop taking this medication and call my provider." c. "I will be careful not to gain too much weight while taking this medication." d. "This medication is highly addictive and must be withdrawn slowly."
c
A nurse is to complete an AIMS assessment of a client. When explaining this test to the client, the nurse should say that this test will help to identify if the client is beginning to have which of the following? a. weak muscles b. shaking hands and feet c. uncontrollable motions in the body d. slowed body mvt
c
The nurse formulates which priority nursing concern for a client experiencing amnesia associated with high levels of anxiety? a. confusion b. powerlessness c. inability to cope d. impaired sensory perception
c
The school nurse is planning a community education program about childhood mental health problems that appear to be genetically transmitted. While conducting the program, the nurse will emphasize information about which problem? a. anxiety states b. sleepwalking c. enuresis d. oppositional defiance disorder
c
The school nurse is teaching parents of six- and seven-year-old students about anxiety disorders in early school-age children. Which disorder should the nurse emphasize in the discussion? a. OCD b. depression c. separation anxiety disorder d. PTSD
c
What is a priority nursing assessment before the administration of the first dose of olanzapine? a. usual sleep pattern b. food and fluid preferences c. body weight d. hx of indigestion
c
What is a priority nursing concern for a client diagnosed with schizophrenia with residual features? a. interrupted communication b. inability to perform self care c. impaired social interactions d. anxiety
c
What is the most appropriate nursing intervention for a client diagnosed with schizophrenia who looks away from the nurse and stares at the wall while making a facial grimace? a. end the conversation, bc the client is not listening b. administer the prescribed prn trihexyphenidyl c. ask if the client see something on the wall d. redirect the conversation to a neutral topic
c
What should be the nurse's best response to a client diagnosed with schizoaffective disorder who asks for an explanation of the action of the prescribed haloperidol and valproic acid? a. "Haloperidol makes your moods calmer, and valproic acid prevents tight muscles." b. "This combination is good for people who have problems like yours." c. "Haloperidol improves your thinking, and valproic acid stabilizes your moods." d. "This is an old combination of drugs that helps people to keep thinking and feelings in balance."
c
What should the nurse do next for a client who recently began taking a typical antipsychotic medication and is experiencing general body rigidity, diaphoresis, a body temperature of 39.4 C (103 F), and a pulse of 130 beats per minute? a. administer the prescribed prn anticholinergic medication b. assess the client for indications of orthostatic hypotension c. begin preparing the client for immediate transfer to an ED d. arrange for an additional healthcare provider's visit later in the day
c
When planning the care of a 6 year old child with oppositional defiant disorder, the psychiatric nurse should include which of the following? a. reminiscence therapy b. emotive therapy c. behavior modification d. cognitive reframing
c
The parent of a child recently diagnosed with oppositional defiant disorder (ODD) asks the nurse to name behaviors associated with the condition. Which information should the nurse include in an answer? (select all that apply) a. cruelty b. stealing c. argumentativeness d. irritability e. arson
c, d
A 3 year old client has been diagnosed with ADHD. A friend of the parents told them that the child will likely receive "lots of drugs." The nurse should reply that the child will most likely be prescribed which of the following drugs? (select all that apply) a. amitriptyline b. paroxetine c. amphetamine and dextroamphetamine d. haloperidol e. atomoxetine
c, e
The nurse assessing the client in a fugue state should look for which of the following? (select all that apply) a. a hx of childhood trauma b. coexisting depression c. exposure to a major stressor d. dissociative episodes e. a recent hx of being raped
c, e
A client who has DID is now 20 minutes late for cognitive therapy group. The client says, "I was never told to go to that group." What is the nurse's best response? a. "You can't get out of group that easily." b. "People with dissociative identify disorder forget quite a bit." c. "Have you thought about just why you might be resisting treatment?" d. "It is possible that you were not aware of group time."
d
A windstorm severely damaged a client's farm. The client recalls very little about the storm and repeatedly says, "I can't believe the farm is destroyed." Which goal would be most helpful? a. report decreased depression by day 2 b. express anger about his loss by day 2 c. apply for job retraining by day 2 d. attend a support group for disaster survivors by day 2
d
The nurse is conducting a client teaching session about dissociative disorders. Which client statement indicates to the nurse an understanding of important concepts about the disorder? a. "People with dissociative disorder usually have gradual loss of memory for names and phone numbers." b. "Dissociative disorders serve as a means of avoiding adult responsibilities." c. "Dissociative disorders are caused from past use of hallucinogens." d. "People develop dissociative disorders to protect themselves from extreme anxiety."
d
The nurse is providing community education about autism to a group of parents. The nurse concludes that teaching has been effective if the parents describe which of the following as common behavioral signs of autism? a. highly creative, imaginative play b. early development of language c. overly affectionate behavior toward parents d. indifference to being held or hugged
d
The parent of a child with ADHD tells the nurse that the child doesn't follow instructions well. Which strategy should the nurse recommend to the parent? a. "Teach you child to be less aggressive and more assertive." b. "Consider developing a predictable daily routine." c. "It could be helpful to assign a time out if instructions aren't followed." d. "Try having you child repeat what was said before starting the task."
d
Which of the following manifestations should the nurse teach a client to report to the healthcare provider immediately while taking clozapine? a. feelings of increased energy and interest in the environment b. unusual rxns to exposures to the sun c. interferences with the normal sleep pattern d. indications of any sort of infection
d
Which priority nursing concerns should be given highest priority for a client who exhibits paranoia, has been admitted to an acute care psychiatric hospital unit, and has been diagnosed with schizophrenia? a. alterations in thought processes b. impaired social relationships c. inadequate communication d. risk for violence inflicted toward self or others
d
dissociation
defense mechanism in which experiences are blocked off from consciousness, so that affect, behavior, identity, memories, and thoughts are not integrated
repression
defense mechanism in which thoughts and feelings are kept from consciousness
dissociative identity disorder (DID)
dissociative disorder characterized by 2 or more distinct personalities or identities (alters) in an individual person; formerly called multiple personality disorder
dissociative fugue
dissociative disorder characterized by suddenly wandering or taking a trip away from one's usual place, accompanied by amnesia for some or all of the past
dissociative amnesia
dissociative disorder in which there is an inability to remember important personal info that cannot be accounted for by ordinary forgetfulness; dissociative fugue may be a part of the amnesia
hallucinations
false sensory perceptions that may involve any of the 5 senses (auditory [including command], visual, tactile, olfactory, and gustatory)
depersonalization
feeling of detachment or separation from one's self, as if in a dream-like state
generalized amnesia
inability to recall entire life
localized amnesia
inability to recall events in a circumscribed time period
selective amnesia
inability to recall some events within a circumscribed time
continuous amnesia
inability to recall successive events as they occur
neologisms
new words that are invented by and have meaning to only one person
alter
personality state or identify that recurrently takes over the behavior of an individual with dissociative identity disorder
catatonic
position of the body in a fixed, wax-like state
host personality
primary identity that holds the person's name
clang association
rhyming of words in a sentence that make no sense
word salad
the combining of words in a sentence that have no connection and make no sense
thought control
the delusional belief that others can control a person's thoughts against one's will
thought broadcasting
the delusional belief that others can hear one's thoughts
thought insertion
the delusional belief that others have the ability to put thoughts in a person's mind against one's will
depersonalization/derealization disorder
type of dissociative disorder that consists of persistent or recurrent feelings of being detached from one's body or mental processes, usually with a feeling of being an outside observer of one's life, or of being detached from one's surroundings
