MH Final Review questions #2

28. Joe, who recently lost both parents in a tragic automobile accident, has been diagnosed with an adjustment disorder after he struck a friend who told him he needed to "get his feelings out." The stage of grieving that Joe is struggling with is ____________________.

Anger

95. Screening enables the nurse or other health-care professional to determine whether trauma-informed care is needed at the level of primary, secondary, or tertiary prevention. Match the following to the correct level of prevention: _____Primary _____Secondary _____Tertiary a. When there are negative effects on health that are influenced by trauma history, the nurse refers the patient for specialized post-trauma therapies intended to aidin the patient's recovery process. b. The nurse may teach the patient about the impact of trauma on health, the importance of support systems, self-care, and coping skills. c. The nurse has become informed that there is a history of trauma and intervenes to prevent further sequelae.

B. Primary C. Secondary A. Tertiary

84. A nurse assesses a school-age child who has just been removed from the parental home due to abuse. The health care provider has diagnosed a dissociative disorder. The nurse includes what interventions in the plan of care? (SATA) A. Allow the child the opportunity to confront the abuser during group therapy. B. Tell the child the events that happened to them were not the child's fault. C. Teach the child self-soothing techniques, such as listening to music. D. If the child mentions an imaginary friend, acknowledge the friend as a real person. E. Encourage caregivers to set limits and maintain normal behavior expectations

B. Tell the child the events that happened to them were not the child's fault. C. Teach the child self-soothing techniques, such as listening to music. E. Encourage caregivers to set limits and maintain normal behavior expectations

27. Exposure to trauma has been associated with hyperarousal of the sympathetic nervous system, excessive amygdala activity, and decreased volume of the ____________________.

Hippocampus

25. A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? a. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." b. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." c. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." d. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."

a. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder."

34. A nursing instructor is teaching about the etiology of dissociative disorders from a psychoanalytical perspective. What student statement about clients diagnosed with this disorder indicates that learning has occurred? a. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." b. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. c. "People with dissociative disorders typically have strong egos." d. "There is clear and convincing evidence of a familial predisposition to this disorder."

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

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

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

58. Which of the following situations best describes acute grief? a. A client feels extreme pain over the death of a child four months earlier. b. A client commits suicide because he can no longer handle the sadness of a break up c. A nurse sits with a client while he cries over the death of his father. d. A person is suddenly overwhelmed and starts to cry when she sees a picture of her deceased friend.

a. A client feels extreme pain over the death of a child four months earlier.

59. A nurse is caring for a woman whose mother died six months ago and who is grieving over the loss. The nurse assesses the woman for any signs of complicated grief patterns. Based on the nurse's understanding of this condition, the nurse knows to look for what signs that indicate complicated grief? Select all that apply. a. A complete focus on the deceased person b. A lack of trust in others c. An increase in sexual activity d. Feelings of detachment from the world e. Lack of emotion such as crying or sorrow

a. A complete focus on the deceased person b. A lack of trust in others d. Feelings of detachment from the world

73. A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? a. A rigid posture, restlessness, and glaring. b. Depression and physical withdrawal c. Silence and noncompliance d. Hypervigilance and talk of past violent acts.

a. A rigid posture, restlessness, and glaring.

30. A patient admitted to the hospital with PTSD is ordered the following medications. Which of these medications has a direct use in treating symptoms that are common in PTSD? Select all that apply. a. Alprazolam (Xanax) b. Propanolol (Inderal) c. Docusate sodium (Colace) d. Docusate (Dulcolax)

a. Alprazolam (Xanax) b. Propanolol (Inderal)

8. When planning care for a client, which medication classification would a nurse recognize as effective in the treatment of Tourette syndrome? a. Antipsychotic medications b. Antimanic medications c. Tricyclic antidepressant medications d. Monoamine oxidase inhibitor medications

a. Antipsychotic medications

94. When planning care for a client, which medication classification should the nurse recognize as effective in the treatment of Tourette's disorder? a. Antipsychotic medications b. Antimanic medications c. Tricyclic antidepressant medications d. Monoamine oxidase inhibitor (MAOI) medications

a. Antipsychotic medications

21. A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified? a. Aquaphobia, a natural environment type of phobia b. Aquaphobia, a situational type of phobia c. Acrophobia, a natural environment type of phobia d. Acrophobia, a situational type of phobia

a. Aquaphobia, a natural environment type of phobia

16. A child diagnosed with attention deficit hyperactivity disorder (ADHD) is going to begin medication therapy. The nurse should plan to teach the family about which classification of medications? a. Central nervous system stimulants and non-stimulants b. Monoamine oxidase inhibitors (MAOIs) c. Antipsychotic medications d. Anxiolytic medications

a. Central nervous system stimulants and non-stimulants

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

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

41. The nurse observes dental deterioration when assessing a client diagnosed with Bulimia Nervosa. Which best explains this assessment finding? a. Emesis from purging corrodes the tooth enamel. b. Purging causes the depletion of dietary calcium. c. Food is rapidly ingested without proper mastication. d. Poor dental and oral hygiene leads to dental caries.

a. Emesis from purging corrodes the tooth enamel.

91. When someone falsely claims that another person has physical or psychological signs or symptoms of illness, or causes injury or disease in another person with the intention of deceiving others is called: a. Factitious disorder imposed on another b. Malingering Syndrome c. Fictitious disorder imposed on self d. Somatic system disorder

a. Factitious disorder imposed on another

78. The nurse cares for a client with post-traumatic stress disorder (PTSD). What interventions does the nurse include? (SATA) a. Help the client establish predictable daily routines. b. Discourage the client from focusing on the trauma. c. Educate the client on sleep hygiene practice. d. Encourage the client to engage in support groups. e. Help the client accept responsibility for traumatic event.

a. Help the client establish predictable daily routines. c. Educate the client on sleep hygiene practice. d. Encourage the client to engage in support groups.

82. The nurse cares for a client diagnosed with dissociative identity disorder. During the examination, the nurse would expect which symptoms? (SATA) a. Inability to recall events b. Unstable relationships c. Intense egocentrism d. Preoccupation with physical appearance e. Inconsistent performance on assessments

a. Inability to recall events b. Unstable relationships e. Inconsistent performance on assessments

67. Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse: a. Increased attention span and concentration. b. Increase in appetite. c. Sleepiness and lethargy. d. Bradycardia and diarrhea.

a. Increased attention span and concentration.

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

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

5. A 9-year-old child has been diagnosed with ADHD and is acting impulsively with hyperactivity. Which developmental activity would most likely be difficult for this child to achieve? a. Social interaction and making friends. b. Performing in gym classes and at sports c. Finding creative solutions to problems d. Talking to different groups of people

a. Social interaction and making friends.

76. A client with a recurring compulsion to organize has found a successful closet organizing business. The nurse documents this history as an example of what phenomenon? a. Sublimination b. Projection c. Reaction Formation d. Displacement

a. Sublimination Rationale: A is correct: This is an example of sublimation. The client is subconsciously applying the abnormal need for order into an activity that is more socially acceptable.

79. The nurse cares for a client reporting paralysis of both legs. The client is diagnosed with conversion disorder. Which nursing intervention does the nurse implement? a. Teach client deep breathing techniques for relaxation. b. Explain to the client that the legs are not paralyzed. c. Focus nursing time on assessing the client's legs. d. Insist the client ambulate with assistance to the bathroom.

a. Teach client deep breathing techniques for relaxation.

87. The nurse cares for older adults in a clinic setting. Which client situation does the nurse consider a warning sign of elder abuse? a. The client's adult child insists on staying in the exam room during the client's clinic visit. b. The client has a large ecchymotic area on the anterior aspect of the knee from a reported fall at home. c. The client reports the home air conditioner is not working and will not be repaired until next week despite the summer heat. d. The client reports an adult child pays the client's utility bills using the client's checking account.

a. The client's adult child insists on staying in the exam room during the client's clinic visit.

29. A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (eye movement desensitization and reprocessing) therapy. The nurse is asked to conduct an assessment to validate the patient's appropriateness for this treatment. Which of the following data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply. a. The patient has a history of a seizure disorder. b. The patient has a history of electroconvulsive therapy (ECT). c. The patient reports suicidal ideation with a plan. d. The patient has been using alcohol in increasing quantities over the last 3 months.

a. The patient has a history of a seizure disorder. c. The patient reports suicidal ideation with a plan. d. The patient has been using alcohol in increasing quantities over the last 3 months.

81. The nurse cares for a client with an anxiety disorder. The nurse assesses for what behaviors as evidence the client is experiencing a panic attack. (SATA) a. Visual hallucinations b. Disoriented to surroundings c. Disorganized thinking d. Decreased energy level e. Performing rituals

a. Visual hallucinations b. Disoriented to surroundings c. Disorganized thinking

44. During an assessment interview, a client diagnosed with Antisocial Personality Disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? a. "You are very disrespectful. You need to learn to control yourself." b. "I understand that you are angry, but this behavior will not be tolerated." c. "What behaviors could you modify to improve this situation?" d. "What antipersonality disorder medications have helped you in the past?"

b. "I understand that you are angry, but this behavior will not be tolerated."

9. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of IDD? a. Risk for injury R/T self-mutilation b. Altered social interaction R/T nonadherence to social convention. c. Altered verbal communication R/T delusional thinking. d. Social isolation R/T severely decreased gross motor skills.

b. Altered social interaction R/T nonadherence to social convention.

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

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

77. A nurse cares for a client with a personality disorder. Based on the common characteristics of personality disorders, what actions will the nurse incorporate into the plan of care? (SATA) a. Arranging group discussions with others about personal relationships. b. Establishing non-negotiable consequences for unwanted behavior. c. Offering rewards for honesty and adhering to the treatment plan. d. Encouraging client to identify behavior that resulted in hospitalization. e. Accepting the client's explanation and avoid blaming the client for negative behaviors.

b. Establishing non-negotiable consequences for unwanted behavior. c. Offering rewards for honesty and adhering to the treatment plan. d. Encouraging client to identify behavior that resulted in hospitalization.

50. A nurse cares for a client admitted to the hospital after being assaulted by his or her spouse. The nurse is paged for a phone call. The caller requests information on the status of the client. Which action does the nurse take? a. Request that the caller come to the hospital in person to discuss the client's status. b. Explain to the caller that there is no client admitted matching the description. c. Inform the caller that the client is "stable" with no further elaboration. d. Inform the caller of the client room number and anticipated discharge date.

b. Explain to the caller that there is no client admitted matching the description.

69. A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: a. Manipulate her husband. b. Gain control of one part of her life. c. Commit suicide. d. Live up to her mother's expectations.

b. Gain control of one part of her life.

1. A nurse is assessing an adolescent who has autism spectrum disorder. Which of the following manifestations should the nurse expect? (Select all that apply.) a. Attempts to intimidate others. b. Has delayed language development. c. Spins a toy repetitively. d. Exhibits ritualistic behavior.

b. Has delayed language development. c. Spins a toy repetitively. d. Exhibits ritualistic behavior.

47. A client diagnosed with Borderline Personality Disorder (BPD) brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. Which approach is best for the nursing staff to implement? a. Allow the clients to apply the democratic process when developing unit rules. b. Maintain consistency of care by open communication to avoid staff manipulation. c. Allow the client spokesperson to verbalize concerns during a unit staff meeting. d. Maintain unit order by the application of autocratic leadership.

b. Maintain consistency of care by open communication to avoid staff manipulation.

85. A client is brought in by the police after being found wandering around a grocery store and unable to recall any personal information. What assessment findings does the nurse document as supporting a dissociative fugue? a. Recent involvement in a motor vehicle collision with head injury b. Military background with diagnosis of post-traumatic stress disorder c. Low score on a cognitive assessment such as the Mini-Mental State Exam d. History of substance abuse and multiple opioid overdose incidents

b. Military background with diagnosis of post-traumatic stress disorder

18. What are the primary distinguishing factors between the behavior of children diagnosed with oppositional defiant disorder (ODD) and those diagnosed with conduct disorder (CD)? (Select all that apply.) The child diagnosed with: a. ODD relives traumatic events by acting them out. b. ODD tests limits and disobeys authority figures. c. ODD has difficulty separating from the parents. d. CD uses stereotypical or repetitive language. e. CD often violates the rights of others.

b. ODD tests limits and disobeys authority figures. e. CD often violates the rights of others.

83. The nurse cares for an adult client with severe separation anxiety disorder. The anxiety is focused on the client's mother. What does the nurse include in the plan of care? (SATA) a. Encourage the client's mother to stop by the unit for frequent, informal visits with the client. b. Offer reassurance when the client is anxious, reminding of previous visits, and referring to pictures of the two together. c. Help the client's mother learn how to set healthy boundaries with the client. d. Establish good sleep hygiene and monitor quality and quantity of sleep closely. e. Immediately after the mother ends a visit, teach the client anxiety-reduction techniques.

b. Offer reassurance when the client is anxious, reminding of previous visits, and referring to pictures of the two together. c. Help the client's mother learn how to set healthy boundaries with the client. d. Establish good sleep hygiene and monitor quality and quantity of sleep closely.

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

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

49. A home health nurse makes weekly visits to an older adult client who lives with an adult child. The client has bruises from "bumping into things" and a weight loss of 10 pounds in the past month. How does the nurse proceed? a. Ask the client about any concerns about his or her living situation with the child in the room. b. Report suspected abuse to Adult Protective Services so an investigation can be performed. c. Question the client's child privately about suspicions of possible abuse or neglect. d. Confront the child about the abuse, and demand that the child seek help for the abusive behavior.

b. Report suspected abuse to Adult Protective Services so an investigation can be performed

7. Which finding would a nurse expect when assessing a child diagnosed with separation anxiety disorder? a. The child has a history of antisocial behaviors. b. The child's mother was stressed during the pregnancy. c. The child previously had an extroverted temperament. d. The child's mother and father have an inconsistent parenting style.

b. The child's mother was stressed during the pregnancy.

32. Which is considered an appropriate outcome when planning care for an inpatient client diagnosed with Somatic Symptom Disorder? a. The client will admit to fabricating physical symptoms to gain benefits by day 3. b. The client will list three potential adaptive coping strategies to deal with stress by day 2. c. The client will comply with medical treatments for physical symptoms by day 3. d. The client will openly discuss physical symptoms with staff by day 4.

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

54. A nurse in an emergency Department is assessing a client who experienced a sexual assault. Which of the following findings should the nurse identify as dissociative manifestations of acute distress disorder? Select all that apply. a. the client reports feelings of anger about the assault b. the client is unable to recall the details of the assault. c. the client reports a sudden inability to make their hands move. d. the client has frequented angry outbursts. e. the client has difficulty concentrating on the nurse's assessment.

b. the client is unable to recall the details of the assault. c. the client reports a sudden inability to make their hands move.

53. A child with attention deficit hyperactivity disorder (ADHD) takes methylphenidate. Which client statement most concerns the nurse? a. "My heart feels like it's racing." b. "Sometimes I am not hungry." c. "I feel like I stopped growing." d. "I have gained a few pounds."

c. "I feel like I stopped growing."

88. A nurse cares for a teenaged client diagnosed with bulimia nervosa. The client expresses distress regarding a weight gain of two pounds. Which response by the nurse is best? a. "Your health care provider wants you to gain weight." b. "I felt that way when I had bulimia." c. "Tell me why gaining two pounds is upsetting." d. "Your mom will be happy to see you're not so thin."

c. "Tell me why gaining two pounds is upsetting."

14. The parent of a child diagnosed with Tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response by the nurse is accurate? a. "Perhaps your child was misdiagnosed." b. "Your observation indicates the medication is effective." c. "Tics often change frequency or severity. That doesn't mean they aren't real." d. "This finding is unexpected. How have you been administering your child's medication?"

c. "Tics often change frequency or severity. That doesn't mean they aren't real."

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

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

62. A 58-year-old client is feeling sadness and loss after his mother died. Which best describes the difference between grief and depression? a. A grieving person may suffer mild delusions in their grief, but a depressed person never has this type of thought pattern. b. A grieving person experiences sadness and loss but a depressed person experiences guilt and anger c. A grieving person may have sadness but also sometimes of joy, while a depressed person's feelings are constant. d. A grieving person may have feelings of hopelessness, but a depressed person would act on those feelings.

c. A grieving person may have sadness but also sometimes of joy, while a depressed person's feelings are constant.

48. Which adult client should the nurse recognize as exhibiting the characteristics of a dependent personality disorder? a. A physically healthy client who is dependent on meeting social needs by having contact with 15 cats b. A physically healthy client who has a history of depending on intense relationships to meet basic needs c. A physically healthy client who lives with parents and relies on public transportation d. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

c. A physically healthy client who lives with parents and relies on public transportation

65. A 35-year-old female has intense fear of riding an elevator. She claims, " As if I will die inside." The client is suffering from: a. Agoraphobia b. Social phobia c. Claustrophobia d. Xenophobia

c. Claustrophobia

22. How would the nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? a. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. b. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. c. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. d. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.

c. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life.

33. Dennis has been diagnosed with Somatic Symptom Disorder. As the nurse is talking with Dennis and his family, which of the following statements suggest primary or secondary gains that the physical symptoms are providing for the client? a. The family agrees that Dennis began having physical symptoms after he lost her job. b. Dennis states that even though medical tests have not found anything wrong, he is convinced his headaches are indicative of a brain tumor. c. Dennis's mother reports that someone from the family stays with Dennis each night because the physical symptoms are incapacitating. d. Dennis states he noticed feeling hotter than usual the last time he had a headache.

c. Dennis's mother reports that someone from the family stays with Dennis each night because the physical symptoms are incapacitating.

71. Nurse Penny is aware that the following medical conditions are commonly found in clients with bulimia nervosa? a. Allergies b. Cancer c. Diabetes mellitus d. Hepatitis A

c. Diabetes mellitus

80. A client with antisocial personality disorder suddenly gets angry at the nurse for not being allowed in the staff lounge. How does the nurse respond? a. Remind the client that the nurse is in charge and can administer medication if needed. b. Escort the client to their room and direct them to stay there until they calm down appropriately. c. Enforce the limit calmly, but firmly, and redirect the client to another activity. d. Calm the client by using therapeutic touch and allow client to verbalize

c. Enforce the limit calmly, but firmly, and redirect the client to another activity.

35. An inpatient client is newly diagnosed with Dissociative Identity Disorder (DID) stemming from severe childhood sexual abuse. Which is the priority nursing intervention? a. Encourage exploration of sexual abuse. b. Encourage guided imagery. c. Establish trust and rapport. d. Administer antianxiety medications.

c. Establish trust and rapport.

31. A client diagnosed with Somatic Symptom Disorder is most likely to exhibit which personality disorder characteristics? a. Uses "splitting" and manipulation in relationships b. Is socially irresponsible, exploitative, and guiltless and disregards rights of others c. Expresses heightened emotionality, seductiveness, and strong dependency needs d. Uncomfortable in social situations; perceived as timid, withdrawn, cold, and strange

c. Expresses heightened emotionality,

74. Nurse Fey is aware that the drug of choice for treating Tourette syndrome. a. Fluoxetine (Prozac) b. Fluvoxamine (Luvox) c. Haloperidol (Haldol) d. Paroxetine (Paxil)

c. Haloperidol (Haldol)

70. Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband: a. Has only moderate impulse control. b. Denies feelings of jealousy or possessiveness. c. Has learned violence as an acceptable behavior. d. Feels secure in his relationship with his wife.

c. Has learned violence as an acceptable behavior.

4. A 14-year-old teen has been hospitalized for acute exacerbation of ADHD symptoms. The nurse tries to help the client to engage with others on the unit. Which of the following interventions would be most appropriate for supporting social interaction for this client? a. Have the client sit and talk with another client in a one-to-one setting. b. Bring the client to sit with another teen who is playing a video game. c. Help the child join a structured game with other children. d. Avoid social interactions until the ADHD symptoms are under control.

c. Help the child join a structured game with other children.

46. A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should the nurse associate with these assessment data? a. Compulsive personality disorder b. Schizotypal personality disorder c. Histrionic personality disorder (HPD) d. Manic personality disorder

c. Histrionic personality disorder (HPD)

24. Which treatment should the nurse identify as most appropriate for clients diagnosed with GAD? a. Long-term treatment with diazepam (Valium) b. Acute symptom control with citalopram (Celexa) c. Long-term treatment with buspirone (BuSpar) d. Acute symptom control with ziprasidone (Geodon)

c. Long-term treatment with buspirone (BuSpar)

66. Kitty, a 9-year-old child has a very limited vocabulary and interaction skills. She has an I.Q. of 45. She is diagnosed to have Mental retardation of this classification: a. Profound b. Mild c. Moderate d. Severe

c. Moderate

68. Kathleen is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, the nurse should plan to: a. Severely restrict the client's physical activities. b. Weigh the client daily, after the evening meal. c. Monitor vital signs, serum electrolyte levels, and acid-base balance. d. Instruct the client to keep an accurate record of food and fluid intake.

c. Monitor vital signs, serum electrolyte levels, and acid-base balance.

51. An older client, cared for by family, appears dirty and malnourished. What type of abuse might the nurse suspect? a. Sexual b. Physical c. Neglect d. Emotional

c. Neglect

90. A nurse cares for an adult client who reports to the emergency department immediately after a sexual assault. Which nursing actions are appropriate? (SATA) a. Ask if sexual activity was consensual. b. Make client sign the exam consent form. c. Offer a support person or crisis advocate. d. Offer to provide client care for injuries. e. Immediately contact the local law enforcement.

c. Offer a support person or crisis advocate. d. Offer to provide client care for injuries.

11. Which would be the priority nursing intervention when caring for a child diagnosed with conduct disorder? a. Modify environment to decrease stimulation and provide opportunities for quiet reflection. b. Convey unconditional acceptance and positive regard. c. Recognize escalating aggressive behavior and intervene before violence occurs. d. Provide immediate positive feedback for appropriate behaviors.

c. Recognize escalating aggressive behavior and intervene before violence occurs.

72. A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of: a. Ineffective individual coping related to feelings of guilt. b. Situational low self-esteem related to feelings of loss of control. c. Risk for violence: Self-directed related to impulsive mutilating acts. d. Risk for violence: Directed toward others related to verbal threats.

c. Risk for violence: Self-directed related to impulsive mutilating acts.

13. What is the nurse's priority focused assessment for side effects in a child taking methylphenidate for ADHD? a. Dystonia, akinesia, and extrapyramidal symptoms b. Bradycardia and hypotensive episodes c. Sleep disturbances and weight loss d. Neuroleptic malignant syndrome

c. Sleep disturbances and weight loss

57. A nurse is caring for a client who lost her father to cancer last year. The client is demonstrating dysfunctional grief in that she has intense feelings of guilt over the situation. Which of the following factors would increase a person's risk of developing dysfunctional grief? a. The age of the person when they died. b. A lack of religious beliefs c. Social isolation in the grieving person d. A prior experience with loss

c. Social isolation in the grieving person

15. A desired outcome for a 12-year-old diagnosed with oppositional defiant disorder (ODD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Bibliotherapy b. Music therapy c. Social skills groups d. Behavior modification

c. Social skills groups

26. A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? a. Teach deep-breathing relaxation exercises. b. Place the client in a Trendelenburg position. c. Stay with the client and offer reassurance of safety. d. Administer the ordered prn buspirone (BuSpar).

c. Stay with the client and offer the reassurance of safety.

64. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? a. The child cries uncontrollably throughout the examination. b. The child pulls away from contact with the physician. c. The child doesn't cry when the shoulder is examined. d. The child doesn't make eye contact with the nurse.

c. The child doesn't cry when the shoulder is examined.

43. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should the nurse identify as an appropriate indicator of a positive client behavioral change? a. The client gains 2 pounds in 1 week. b. The client focuses conversations on nutritious food. c. The client demonstrates healthy coping mechanisms that decrease anxiety. d. The client verbalizes an understanding of the etiology of the disorder.

c. The client demonstrates healthy coping mechanisms that decrease anxiety.

93. The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurse's assessment? a. The client's spouse died 12 months ago. b. The client still cries when recalling memories of the deceased. c. The client reports feelings of worthlessness. d. The client reports intermittent anxiety.

c. The client reports feelings of worthlessness.

40. A client's altered body image is evidenced by claims of "feeling fat," even though the client is emaciated. Which is the appropriate outcome criterion for this client's problem? a. The client will consume adequate calories to sustain normal weight. b. The client will cease strenuous exercise programs. c. The client will perceive an ideal body weight and shape as normal. d. The client will not express a preoccupation with food.

c. The client will perceive an ideal body weight and shape as normal.

39. Family dynamics are thought to be a major influence in the development of anorexia nervosa. Which information related to a client's home environment should the nurse associate with the development of this disorder? a. The home environment maintains loose personal boundaries. b. The home environment places an overemphasis on food. c. The home environment is overprotective and demands perfection. d. The home environment condones corporal punishment.

c. The home environment is overprotective and demands perfection.

45. A client diagnosed with Paranoid Personality Disorder becomes violent on a unit. Which nursing intervention is most appropriate? a. Provide objective evidence that violence is unwarranted. b. Initially restrain the client to maintain safety. c. Use clear, calm statements and a confident physical stance. d. Empathize with the client's paranoid perceptions.

c. Use clear, calm statements and a confident physical stance.

17. A 15-year-old adolescent has run away from home six times. After the adolescent was arrested for prostitution, the parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. The adolescent's problem is most consistent with criteria for: a. attention deficit hyperactivity disorder (ADHD). b. childhood depression. c. conduct disorder (CD). d. autism spectrum disorder (ASD).

c. conduct disorder (CD).

2. A nurse is assessing a child who has autism spectrum disorder. Which of the following findings should the nurse expect? a. Preoccupation of thoughts b. associative looseness c. echolalia d. magical thinking

c. echolalia

12. After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which of the following symptoms would a student nurse recognize? a. Arguing and annoying an older sibling over the past year b. Angry and resentful behavior over a 3-month period c. Initiating physical fights for more than 18 months d. Arguing with authority figures for more than 6 months

d. Arguing with authority figures for more than 6 months

89. Parents bring a toddler-age client into the emergency department stating, "We are concerned the babysitter is physically abusing our toddler." What action should the nurse take first to care for the client? a. Notify the social worker. b. Call health care provider (HCP). c. Call Child Protective Services (CPS). d. Assess the client.

d. Assess the client.

61. A 35-year-old client is undergoing a lower limb amputation after a crushing injury. Which best describes how the nurse can support the client's anticipated grief during this time? a. Have the client look at images of people who have lost a limb to get used to it b. Ask the provider for medications to manage anxiety. c. Help the client to wrap the extremity to take care of it. d. Assist the client to verbalize feelings related to the loss of a body part.

d. Assist the client to verbalize feelings related to the loss of a body part.

23. How would the nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? a. GAD is acute in nature, and panic disorder is chronic. b. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. c. Hyperventilation is a common symptom in GAD and rare in panic disorder. d. Depersonalization is commonly seen in panic disorder and absent in GAD.

d. Depersonalization is commonly seen in panic disorder and absent in GAD.

10. Which would the nurse identify as risk factors related to family dynamics for predisposition to a conduct disorder? a. Stable residence b. Consistency in discipline c. Excessive supervision d. Economic stressors

d. Economic stressors

63. The parents of a 1-year-old child who has been adopted from Ethiopia ask the nurse about the child's feelings of grief. The mother tells the nurse, "I do not think the understands the loss at one year old." Which response from the nurse is correct? a. The child will not remember this. I would not be concerned with grief. b. You should start counseling with the child now so that the child can talk about this grief later. c. A child does not start to feel grief until he is about 3 years old. d. Even infants can feel grief and loss, even without conscious memory at this age.

d. Even infants can feel grief and loss, even without conscious memory at this age.

60. Which best describes disenfranchised grief? a. Grieving in a manner that does not follow normal patterns. b. Grief that is accompanied with physical complaints. c. Grieving over something that has yet to happen. d. Grief over a loss that cannot be publicly shared.

d. Grief over a loss that cannot be publicly shared.

52. An adolescent client is prescribed methylphenidate. The client's medical history includes attention deficit hyperactivity disorder and atrial septal defect. Which action does the nurse take? a. Obtain the client's surgical history. b. Teach the client how to take their heart rate. c. Ask the client whether the medication is working. d. Notify the health care provider immediately.

d. Notify the health care provider immediately.

86. An adolescent client is prescribed methylphenidate. The client's medical history includes attention deficit hyperactivity disorder and atrial septal defect. Which action does the nurse take? a. Obtain the client's surgical history. b. Teach the client how to take their heart rate. c. Ask the client whether the medication is working. d. Notify the health care provider immediately.

d. Notify the health care provider immediately.

75. A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care? a. Asking the client to compare her figure with magazine photographs of women her age. b. Assigning the client to group therapy in which participants provide realistic feedback about her weight. c. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift. d. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy.

d. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy.

6. Which developmental characteristic would a nurse identify as typical of a client diagnosed with severe intellectual developmental disorder (IDD)? a. The client can perform some self-care activities independently. b. The client has more advanced speech development. c. Other than possible coordination problems, the client's psychomotor skills are not affected. d. The client communicates wants and needs by "acting out" behaviors.

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

56. The parents of a 2-year-old child who died of leukemia are experiencing intense grief in the months following the death. Which of the following is a factor that would affect how these parents experience grief? a. The life history of the person who died. b. The gender of the deceased person c. The illness of the person who died. d. The personality of the grieving person

d. The personality of the grieving person

42. Which indicates the reason behavior modification programs are the treatment of choice for clients diagnosed with eating disorders? a. They help clients correct distorted body image. b. They address underlying client anger. c. They help clients manage uncontrollable behaviors. d. They allow clients to maintain control.

d. They allow clients to maintain control.

3. The parents of a child with autism talk with a nurse about their feelings of being overwhelmed in caring for their child. They state that they do not get a break from their child, the child's needs are almost more than they can handle, and they are considering divorce. Which of the following initial responses from the nurse is most appropriate? a. You can look up several inpatient placement centers online for information about childcare. b. Please do not get a divorce over this. There has to be another solution. c. You may want to consider taking a vacation away together without your child to help with your stress levels. d. You may want to talk with a respite provider who can occasionally care for your child.

d. You may want to talk with a respite provider who can occasionally care for your child.

55. A nurse is caring for a school age child who reports being physically abused by his guardian period which of the Following statements should the nurse make? a. I promise I won't tell anybody about this. b. let's discuss this with your Guardian. c. your Guardian is wrong for doing this to you. d. it's not your fault this happened.

d. it's not your fault this happened.