Psych Final

The child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with: a. attention deficit hyperactivity disorder. b. posttraumatic stress disorder. c. communication disorder. d. an anxiety disorder.

A Antipsychotic medication is useful for managing aggressive or violent behavior in some children diagnosed with attention deficit hyperactivity disorder. If medication were prescribed for a child with an anxiety disorder, it would be a benzodiazepine. Medications are generally not needed for children with communication disorder. Treatment of PTSD is more often associated with SSRI medications.

A child diagnosed with attention deficit hyperactivity disorder will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? a. Central nervous system stimulants c. Antipsychotics b. Tricyclic antidepressants d. Anxiolytics

A Central nervous system stimulants, such as methylphenidate and pemoline (Cylert), increase blood flow to the brain and have proved helpful in reducing hyperactivity in children and adolescents with attention deficit hyperactivity disorder. The other medication categories listed would not be appropriate.

Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? a. The child has been raised by a parent with chronic major depression. b. The child's best friend was absent from the child's birthday party. c. The child was not promoted to the next grade one year. d. The child moved to three new homes over a 2-year period.

A Children raised by a depressed parent have an increased risk of developing an emotional disorder. Familial risk factors correlate with child psychiatric disorders, including severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. The chronicity of the parent's depression means it has been a consistent stressor. The other factors are not as risk- enhancing.

A parent diagnosed with schizophrenia and 13-year-old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "My three friends and I got an A on our school science project." The nurse can assess that the child: a. displays resiliency. b. has a passive temperament. c. is at risk for posttraumatic stress disorder. d. uses intellectualization to deal with problems.

A Resiliency enables a child to handle the stresses of a difficult childhood. Resilient children can adapt to changes in the environment, take advantage of nurturing relationships with adults other than parents, distance themselves from emotional chaos occurring within the family, learn, and use problem-solving skills.

Soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "If my parents loved me, they would work out their problems." Which nursing diagnosis has the highest priority? a. Social isolation c. Chronic low self-esteem b. Decisional conflict d. Disturbed personal identity

A This child shows difficulty coping with problems associated with the family. Social isolation refers to aloneness that the patient perceives negatively, even when self-imposed. The other options are not supported by data in the scenario.

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

A Children diagnosed with autism spectrum disorders display profoundly disturbed social relatedness. They seem aloof and indifferent to others, often preferring inanimate objects to human interaction. Language is often delayed and deviant, further complicating relationship issues. The other nursing diagnoses might not be appropriate in all cases

16. Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

ANS: A Because the individual who has ingested a hallucinogen is probably experiencing feelings of unreality and altered sensory perceptions, the best environment is one that does not add to the stimulation. A simple, safe environment is a better choice than an environment with any of the characteristics listed in the other options. The other options would contribute to a "bad trip."

18. At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as: a. codependence. b. assertiveness c. role reversal d. homeostasis.

ANS: A Codependence refers to participating in behaviors that maintain the addiction or allow it to continue without holding the user accountable for his or her actions. The other options are not supported by information given in the scenario. See relationship to audience response question.

13. During the third week of treatment, the spouse of a patient in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

ANS: A During recovery, patients identify and use alternative coping mechanisms to reduce reliance on substances. Physical adaptations must occur. Emotional responses were previously dulled by alcohol but are now fully experienced and may cause considerable anxiety. These changes inevitably have an effect on the spouse and children, who need anticipatory guidance and accurate information.

1. A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

ANS: B Admitting to being an alcoholic, making an attempt to remain alcohol-free for a day at a time, and receiving support from peers are basic aspects of AA. The other options are incorrect.

2. Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the patient to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

ANS: A Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Patients with antisocial personality disorders rarely have feelings of fear and inferiority.

11. A patient admitted to an alcoholism rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

ANS: A Minimizing one's drinking is a form of denial of alcoholism. The patient is more than a social drinker. Projection involves blaming another for one's faults or problems. Rationalization involves making excuses. Introjectioninvolves incorporating a quality of another person or group into one's own personality.

23. Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. a. Monitor vital signs. b. Observe for depression. c. Awaken the patient every 15 minutes. d. Use warmers to maintain body temperature.

ANS: A Overdose of stimulants, such as amphetamines, can produce respiratory and circulatory dysfunction as well as hyperthermia. Concentration is impaired. This patient will be hypervigilant; it is not necessary to awaken the patient.

15. Select the most therapeutic manner for a nurse working with a patient beginning treatment for alcohol addiction. a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

ANS: A Support and empathy assist the patient to feel safe enough to start looking at problems. Counseling during the early stage of treatment needs to be direct, open, and honest. The other approaches will increase patient anxiety and cause the patient to cling to defenses.

28. A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine - National Research Council (IOM) c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

ANS: A The Substance Abuse and Mental Health Services Administration (SAMHSA) is the official resource for comprehensive information regarding addictions. The other resources have relevant information, but they are not as comprehensive.

30. Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will: a. state, "I know I need long-term treatment." b. use denial and rationalization in healthy ways. c. identify constructive outlets for expression of anger. d. develop a trusting relationship with one staff member.

ANS: A The key refers to the need for ongoing treatment after detoxification and is the best goal related to controlling relapse. The scenario does not give enough information to determine whether anger has been identified as a problem. A trusting relationship, while desirable, should have occurred earlier in treatment.

17. When a patient first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

ANS: A Tolerance refers to needing higher and higher doses of a drug to produce the desired effect. The potency of the alcohol is stable. Neither hypomagnesemia nor antagonistic effects account for this change.

9. What is the priority nursing diagnosis for a patient diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self directed violence c. Impaired social interaction d. Ineffective denial

ANS: A Violence against property, along with threats to harm staff, makes this diagnosis the priority. Patients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When patients with antisocial personality disorders use denial, they use it effectively.

14. Which nursing intervention has the highest priority for a patient with bulimia nervosa? a. Assist the patient to identify triggers to binge eating. b. Provide corrective consequences for weight loss. c. Assess for signs of impulsive eating. d. Explore patient needs for health teaching.

ANS: A For most patients with bulimia nervosa, certain situations trigger the urge to binge; purging then follows. The triggers are often anxiety-producing situations. Identifying these triggers makes it possible to break the binge-purge cycle. Because binge eating and purging directly affect physical status, the need to promote physical safety assumes the highest priority.

23. Which statement is a nurse most likely to hear from a patient with anorexia nervosa? a. "I'm fat and ugly." b. "I have nice eyes." c. "I'm thin for my height." d. "My parents don't pay much attention to me."

ANS: A Patients with eating disorders have distorted body images; they see themselves as overweight even when their weight is subnormal. "I'm thin for my height" is therefore unlikely to be heard from a patient with anorexia nervosa. Poor self-image precludes making positive statements about self, such as "I have nice eyes." Many patients with eating disorders see supportive others as intrusive and out of tune with their needs.

9. A patient asks for information about Alcoholics Anonymous. Select the nurse's best response. "Alcoholics Anonymous is a: a. form of group therapy led by a psychiatrist." b. self-help group for which the goal is sobriety." c. group that learns about drinking from a group leader." d. network that advocates strong punishment for drunk drivers."

ANS: B Alcoholics Anonymous (AA) is a peer support group for recovering alcoholics. Neither professional nor peer leaders are appointed.

15. One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from: a. 150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 36° C; pulse, 50 beats/min; blood pressure, 70/50 mm Hg c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 36.5° C; pulse, 60 beats/min; blood pressure, 80/66 mm Hg d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 36.7° C; pulse, 62 beats/min; blood pressure, 74/48 mm Hg

ANS: A Physical criteria for hospitalization include weight loss of more than 30% of body weight within 6 months, temperature below 36° C (hypothermia), heart rate less than 40 beats/min, and systolic blood pressure less than 70 mm Hg.

20. Physical assessment of a patient with bulimia often reveals: a. prominent parotid glands. b. peripheral edema. c. thin, brittle hair. d. amenorrhea.

ANS: A Prominent parotid glands are associated with repeated vomiting. The other options are signs of anorexia nervosa and are not usually observed in bulimia.

4. A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis? a. "I'm fat and ugly." b. "What I think about myself is my business." c. "I'm grossly underweight, but that's what I want." d. "I'm a few pounds overweight, but I can live with it."

ANS: A Untreated patients with anorexia nervosa do not recognize their thinness. They perceive themselves to be overweight and unattractive. The patient with anorexia will usually tell others perceptions of self. The patient with anorexia will persist in trying to lose more weight.

25. An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should: a. assess lung sounds and extremities. b. suggest the use of an aerobic exercise program. c. positively reinforce the patient for the weight gain. d. establish a higher goal for weight gain the next week.

ANS: A Weight gain of more than 2 to 5 pounds weekly may overwhelm the heart's capacity to pump, leading to cardiac failure. The nurse must assess for signs of pulmonary edema and congestive heart failure. The incorrect options are undesirable because they increase the risk for cardiac complications.

1. A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply. a. Peripheral edema b. Parotid swelling c. Constipation d. Hypotension e. Dental caries f. Lanugo

ANS: A, C, D, F Peripheral edema is often present because of hypoalbuminemia. Constipation related to starvation is often present. Hypotension is often present because of dehydration. Lanugo is often present and is related to starvation. Parotid swelling is associated with bulimia. Dental caries are associated with bulimia.

2. The nurse can assist a patient to prevent substance abuse relapse by: (select all that apply) a. rehearsing techniques to handle anticipated stressful situations. b. advising the patient to accept residential treatment if relapse occurs. c. assisting the patient to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the patient of physical changes to expect as the body adapts to functioning without substances.

ANS: A, C, E Nurses can be helpful as a patient assesses needed life skills and in providing appropriate referrals. Anticipatory problem solving and role-playing are good ways of rehearsing effective strategies for handling stressful situations and helping the patient evaluate the usefulness of new strategies. The nurse can provide valuable information about physiological changes expected and ways to cope with these changes. Residential treatment is not usually necessary after relapse. Patients need the support of friends and family to establish and maintain sobriety.

10. Police bring a patient to the emergency department after an automobile accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient: a. rarely drinks alcohol. b. has a high tolerance to alcohol. c. has been treated with disulfiram (Antabuse). d. has ingested both alcohol and sedative drugs recently.

ANS: B A non-tolerant drinker would be in coma with a blood alcohol level of 500 mg%. The fact that the patient is moving and talking shows a discrepancy between blood alcohol level and expected behavior and strongly indicates that the patient's body is tolerant. If disulfiram and alcohol are ingested together, an entirely different clinical picture would result. The blood alcohol level gives no information about ingestion of other drugs.

2. A nurse reviews vital signs for a patient admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? a. Force fluids. b. Consult the health care provider. c. Obtain a clean-catch urine sample. d. Place the patient in a vest-type restraint.

ANS: B Elevated pulse and blood pressure may indicate impending alcohol withdrawal and the need for medical intervention. No indication is present that the patient may have a urinary tract infection or is presently in need of restraint. Hydration will not resolve the problem.

7. A patient diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The patient reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Serotonin norepinephrine reuptake inhibitor (SNRI)

ANS: B Mood stabilizing medications have been effective for many patients with borderline personality disorder. Serotonin norepinephrine reuptake inhibitors (SNRI) or anxiolytics are not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for patients who are impulsive.

7. A hospitalized patient diagnosed with an alcohol abuse disorder believes spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the patient every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

ANS: B One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes perceptual disturbances. Excessive fluid intake can cause overhydration, because fluid retention normally occurs when blood alcohol levels fall.

3. A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

ANS: B Opioid overdose causes respiratory depression. Respiratory depression is the primary cause of death among opioid abusers. The assessment of the other body systems is relevant but not the priority. See relationship to audience response question.

6. A hospitalized patient diagnosed with an alcohol abuse disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n): a. narcotic analgesic, such as hydromorphone (Dilaudid). b. sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium). c. antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). d. monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil).

ANS: B Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.

19. In the emergency department, a patient's vital signs are BP 66/40 mm Hg; pulse 140 beats/min; respirations 8 breaths/min and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to narcotic intoxication. Select the priority outcome. a. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/min, and respirations at or above 12 breaths/min. c. The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields.

ANS: B The correct short-term outcome is the only one that relates to the patient's physical condition. It is expected that vital signs will return to normal when the CNS depression is alleviated. The patient's respirations are slow and shallow, but there is no evidence of congestion.

27. An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

ANS: B The patient who is high on a hallucinogen often experiences synesthesia (visions in sound), depersonalization, and concerns about going "crazy." Synesthesia is not common in schizophrenia. CNS stimulant overdose more commonly involves elevated vital signs and assaultive, grandiose behaviors. Phencyclidine (PCP) use commonly causes bizarre or violent behavior, nystagmus, elevated vital signs, and repetitive jerking movements.

24. Symptoms of withdrawal from opioids for which the nurse should assess include: a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

ANS: B The symptoms of withdrawal from opioids are similar to those of alcohol withdrawal. Hyperthermia is likely to produce periods of diaphoresis. See relationship to audience response question. (Educators may alter this question to multiple answers if desired.)

8. A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain? a. Because severe anxiety concerning eating is expected, objective and subjective data must be routinely collected. b. Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment. c. A team approach to planning the diet ensures that physical and emotional needs are met. d. Because of increased risk of physical problems with refeeding, obtaining patient permission is essential.

ANS: B A sense of control for the patient is vital to the success of therapy. A diet that controls weight gain can allay patient fears of a too-rapid weight gain. Data collection is not the reason for contracting. A team approach is wise but is not a guarantee that needs will be met. Permission for treatment is a separate issue. The contract for weight gain is an additional aspect of treatment.

12. What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision? a. The nurse's comments are nonjudgmental. b. The nurse uses an authoritarian manner when interacting with the patient. c. The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. d. The nurse refers the patient to a self-help group for individuals with eating disorders.

ANS: B In the effort to motivate the patient and take advantage of the decision to seek help and be healthier, the nurse must take care not to cross the line toward authoritarianism and assume the role of a parent. The helpful nurse uses a problem-solving approach and focuses on the patient's feelings of shame and low self-esteem. Referral to a self-help group is an appropriate intervention.

11. An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to: a. eat a small meal after purging. b. avoid skipping meals or restricting food. c. concentrate intake after 4 PM daily. d. understand the value of reading journal entries aloud to others.

ANS: B One goal of health teaching is the normalization of eating habits. Food restriction and skipping meals lead to rebound bingeing. Teaching the patient to eat a small meal after purging will probably perpetuate the need to induce vomiting. Teaching the patient to concentrate intake after 4 PM will lead to late-day bingeing. Journal entries are private.

21. Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa? a. Carefree flexibility b. Rigidity, perfectionism c. Open displays of emotion d. High spirits and optimism

ANS: B Rigid thinking, inability to demonstrate flexibility, and difficulty changing cognitions are characteristic of patients with eating disorders. The incorrect options are rare in a patient with an eating disorder. Inflexibility, controlled emotions, and pessimism are more the norm.

7. Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditure and caloric intake.

ANS: B The nursing intervention of observing for adverse effects of refeeding most directly relates to weight gain and is a priority. Assessing for depression and anxiety and communicating empathy relate to coping. Helping the patient balance energy expenditure and caloric intake is an inappropriate intervention.

1. A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to: (select all that apply) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

ANS: B, C, F The patient must avoid hidden sources of alcohol. Many liquid medications, such as cough syrups, contain small amounts of alcohol that could trigger an alcohol-disulfiram reaction. Using alcohol-based skin products such as aftershave or cologne, smelling alcohol-laden fumes, and eating foods prepared with wine, brandy, or beer may also trigger reactions. The other options do not relate to hidden sources of alcohol.

14. The treatment team discusses the plan of care for a patient diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should: a. provide long-term care for the patient in a residential facility. b. withdraw the patient from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

ANS: C Both diagnoses should be considered primary and receive simultaneous treatment. Comorbid disorders require longer treatment and progress is slower, but treatment may occur in the community.

6. A nurse reports to the treatment team that a patient diagnosed with an antisocial personality disorder has displayed the behaviors below. This patient is detached and superficial during counseling sessions. Which behavior by the patient most clearly warrants limit setting? a. Flattering the nurse b. Lying to other patients c. Verbal abuse of another patient d. Detached superficiality during counseling

ANS: C Limits must be set in areas in which the patient's behavior affects the rights of others. Limiting verbal abuse of another patient is a priority intervention and particularly relevant when interacting with a patient diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.

25. A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: a. cross-tolerance. b. substance abuse c. substance addiction. d. substance intoxication.

ANS: C Nicotine meets the criteria for a "substance," the criterion for addiction is present, and withdrawal symptoms are noted with abstinence or reduction of dose. The scenario does not meet criteria for substance abuse, intoxication, or cross-tolerance.

5. Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be assessed as: a. seductive. b. detached c. manipulative. d. guilt-producing.

ANS: C Patients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The patient is displaying the opposite of detached behavior. Guilt is not evident in the comments.

4. A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.

ANS: C Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

3. As a nurse prepares to administer medication to a patient diagnosed with a borderline personality disorder, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the patient. Leave the medication on the table as requested. b. Respond to the patient, "I'm worried that you might not take it. I'll come back later." c. Say to the patient, "I must watch you take the medication. Please take it now." d. Ask the patient, "Why don't you want to take your medication now?"

ANS: C The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital for the patient's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic. See relationship to audience response question.

31. A nurse prepares for an initial interaction with a patient with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the patient. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

ANS: C The nurse should show compassion, care, and helpfulness for all patients, including those with addictive diseases. It is important to have a clear understanding of one's own perspective. Negative feelings may occur for the nurse; supervision is an important resource. The activities identified in the distracters occur after self-assessment.

4. What is an appropriate initial outcome for a patient diagnosed with a personality disorder who frequently manipulates others? The patient will: a. identify when feeling angry. b. use manipulation only to get legitimate needs met. c. acknowledge manipulative behavior when it is called to his or her attention. d. accept fulfillment of his or her requests within an hour rather than immediately.

ANS: C This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The patient would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.

3. A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient: a. "Do you often feel fat?" b. "Who plans the family meals?" c. "What do you eat in a typical day?" d. "What do you think about your present weight?"

ANS: C Although all the questions might be appropriate to ask, only "What do you eat in a typical day?" focuses on the eating patterns. Asking if the patient often feels fat focuses on distortions in body image. Questions about family meal planning are unrelated to eating patterns. Asking for the patient's thoughts on present weight explores the patient's feelings about weight.

16. While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about: a. self-monitoring of daily food and fluid intake. b. establishing the desired daily weight gain. c. recognizing the symptoms of hypokalemia. d. self-esteem maintenance.

ANS: C Hypokalemia results from potassium loss associated with vomiting. Physiologic integrity can be maintained if the patient can self-diagnose potassium deficiency and adjust the diet or seek medical assistance. Self-monitoring of daily food and fluid intake is not useful if the patient purges. Daily weight gain may not be desirable for a patient with bulimia nervosa. Self-esteem is an identifiable problem but is of lesser priority than the risk for hypokalemia.

1. Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely? a. Binge eating b. Bulimia nervosa c. Anorexia nervosa d. Eating disorder not otherwise specified

ANS: C Overly controlled eating behaviors, extreme weight loss, amenorrhea, preoccupation with food, and wearing several layers of loose clothing to appear larger are part of the clinical picture of an individual with anorexia nervosa. The individual with bulimia usually is near normal weight. The binge eater is often overweight. The patient with an eating disorder not otherwise specified may be obese.

17. As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented? a. Amenorrhea b. Alopecia c. Lanugo d. Stupor

ANS: C The fine, downy hair noted by the nurse is called lanugo. It is frequently seen in patients with anorexia nervosa. None of the other conditions can be supported by the data the nurse has gathered.

4. A new patient beginning an alcoholism rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply. a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

ANS: C, D The correct answers give information, summarize, and validate what the patient reported but are not strongly confrontational. Defenses cannot be removed until healthier coping strategies are in place. Strong confrontation does not usually take place so early in the program.

2. A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply. a. Flexible mealtimes b. Unscheduled weight checks c. Adherence to a selected menu d. Observation during and after meals e. Monitoring during bathroom trips f. Privileges correlated with emotional expression

ANS: C, D, E Priority milieu interventions support the restoration of weight and a normalization of eating patterns. These goals require close supervision of the patient's eating habits and the prevention of exercise, purging, and other activities. Menus are strictly adhered to. Patients are observed during and after meals to prevent them from throwing away food or purging. All trips to the bathroom are monitored. Mealtimes are structured, not flexible. Weighing is performed on a regular schedule. Privileges are correlated with weight gain and treatment plan compliance.

26. Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

ANS: D Heroin, an opiate, is a CNS depressant. Blood pressure, pulse, and respirations will be decreased, and attention will be impaired. The distracters describe behaviors consistent with amphetamine use, symptoms of narcotic withdrawal, and cocaine use. (Educators may alter this question to multiple answers if desired.)

12. Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? a. Bromocriptine (Parlodel) b. Methadone (Dolophine) c. Disulfiram (Antabuse) d. Naltrexone (ReVia)

ANS: D Naltrexone (ReVia) is useful for treating both opioid and alcohol addiction. An opioid antagonist blocks the action of opioids and the mechanism of reinforcement. It also reduces or eliminates alcohol craving.

20. Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" Select the nurse's best response. a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

ANS: D Often, the addicted individual has been enabled when others picked up the pieces for him or her. The individual never faced the consequences of his or her own behaviors, all of which relate to taking responsibility. Learning to face those consequences is part of the recovery process. The other options are codependent behaviors or are of no help.

1. A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I should get the money." These statements show: a. shame. b. suspiciousness c. superficial remorse. d. lack of guilt feelings.

ANS: D Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The patient's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.

22. A patient with an antisocial personality disorder was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

ANS: D Residential programs and therapeutic communities help patients change lifestyles, abstain from drugs, eliminate criminal behaviors, develop employment skills, be self-reliant, and practice honesty. Residential programs are more effective for patients with antisocial tendencies than outpatient programs.

8. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

ANS: D The correct response will help the patient see alcohol as a cause of the problems, not a solution, and begin to take responsibility. This approach can help the patient become receptive to the possibility of change. The other responses directly confront and attack defenses against anxiety that the patient still needs. They reflect the nurse's frustration with the patient.

21. Which goal for treatment of alcoholism should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiologic stability.

ANS: D The individual must have completed withdrawal and achieved physiologic stability before he or she is able to address any of the other treatment goals.

8. A patient's spouse filed charges after repeatedly being battered. The patient sarcastically says, "I'm sorry for what I did. I need psychiatric help." Which statement by the patient supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

ANS: D The patient with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Patients with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are common.

5. A patient admitted yesterday for injuries sustained while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

ANS: D The patient's clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse's priority. The other diagnoses may apply but are not the priorities of care.

29. A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? a. PCP b. Heroin c. Barbiturates d. Amphetamines

ANS: D The physical symptoms are consistent with CNS stimulation. Suspicion and paranoid ideation are also present. Amphetamine use is likely. PCP use would probably result in bizarre, violent behavior. Barbiturates and heroin would result in symptoms of CNS depression.

26. When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state: a. "You and I will have to sit down and discuss this problem." b. "It bothers me to see you exercising. You'll lose more weight." c. "Let's discuss the relationship between exercise and weight loss and how that affects your body." d. "According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

ANS: D A matter-of-fact statement that the nurse's perceptions are different helps avoid a power struggle. Treatment plans have specific goals for weight restoration. Exercise is limited to promote weight gain. Patients must be held accountable for required behaviors.

2. Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor? a. Weight, muscle, and fat are congruent with height, frame, age, and sex. b. Calorie intake is within the required parameters of the treatment plan. c. Weight reaches the established normal range for the patient. d. Patient expresses satisfaction with body appearance.

ANS: D Body image disturbances are considered improved or resolved when the patient is consistently satisfied with his or her own appearance and body function. This consideration is subjective. The other indicators are more objective but less related to the nursing diagnosis.

19. A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of: a. Maintaining patients' concentration and attention. b. Shifting the patients' focus from food to psychotherapy. c. Focusing on weight control mechanisms and food preparation. d. Processing the heightened anxiety levels associated with eating.

ANS: D Eating produces high anxiety for patients with eating disorders. Anxiety levels must be lowered if the patient is to be successful in attaining therapeutic goals. Shifting the patients' focus from food to psychotherapy and focusing on weight control mechanisms and food preparation are not desirable. Maintaining patients' concentration and attention is important, but not the primary purpose of the schedule.

6. Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will: a. Weigh self accurately using balanced scales. b. Limit exercise to less than 2 hours daily. c. Select clothing that fits properly. d. Gain 1 to 2 pounds.

ANS: D Only the outcome of a gain of 1 to 2 pounds can be accomplished within 1 week when the patient is an outpatient. The focus of an outcome is not on the patient weighing self. Limiting exercise and selecting proper clothing are important, but weight gain takes priority.

9. A nursing care plan for a patient with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction? a. Renal b. Endocrine c. Central nervous d. Cardiovascular

ANS: D Refeeding resulting in a too-rapid weight gain can overwhelm the heart, resulting in cardiovascular collapse. Focused assessment becomes a necessity to ensure patient physiologic integrity. The other body systems are not initially involved in the refeeding syndrome.

22. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

ANS: D Systolic blood pressure less than 70 mm Hg is an indicator for inpatient care. Many people without eating disorders have bradycardia (pulse less than 60 beats/min). Urine output should be more than 30 ml/hr. A potassium level of 3.4 mEq/L is within the normal range.

10. A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy? a. "What are your feelings about not eating the food that you prepare?" b. "You seem to feel much better about yourself when you eat something." c. "It must be difficult to talk about private matters to someone you just met." d. "Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

ANS: D The correct response is the only strategy that attempts to question the patient's distorted thinking.

13. A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. The best outcome related to this diagnosis is that within 2 weeks the patient will: a. appropriately express angry feelings. b. verbalize two positive things about self. c. verbalize the importance of eating a balanced diet. d. identify two alternative methods of coping with loneliness.

ANS: D The outcome of identifying alternative coping strategies is most directly related to the diagnosis of Ineffective coping. Verbalizing positive characteristics of self and verbalizing the importance of eating a balanced diet are outcomes that might be used for other nursing diagnoses. Appropriately expressing angry feelings is not measurable.

24. Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges? a. Powerlessness b. Ineffective coping c. Disturbed body image d. Imbalanced nutrition: less than body requirements

ANS: D The patient with bulimia nervosa usually maintains a close to normal weight, whereas the patient with anorexia nervosa may approach starvation. The incorrect options may be appropriate for patients with either anorexia nervosa or bulimia nervosa.

5. A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies? a. Adult failure to thrive, related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss b. Disturbed energy field, related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia c. Ineffective health maintenance, related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia d. Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

ANS: D The patient's history and laboratory results support the fourth nursing diagnosis. Available data do not confirm that the patient uses laxatives, induces vomiting, or exercises excessively. The patient has hypokalemia rather than hyperkalemia.

18. A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis? a. Anxiety, related to fear of weight gain b. Disturbed body image, related to weight loss c. Ineffective coping, related to lack of conflict resolution skills d. Imbalanced nutrition: less than body requirements, related to self-starvation

ANS: D The physical assessment shows cachexia, which indicates imbalanced nutrition. Addressing the patient's self-starvation is the priority.

3. A patient took a large quantity of bath salts. Priority nursing and medical measures include: (select all that apply) a. administration of naloxone (Narcan). b. vitamin B12 and folate supplements. c. restoring nutritional integrity. d. management of heart rate. e. environmental safety.

ANS: D, E Care of patients who have taken bath salts is similar to those who have used other stimulants. Tachycardia and chest pain are common when a patient has used bath salts. These problems are life-threatening and take priority. Patients who have used these substances commonly have bizarre behavior and/or paranoia; therefore, safety is a priority concern. Nutrition is not a priority in an overdose situation. Vitamin replacements and naloxone apply to other drugs of abuse.

A child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action? a. Give notice to the chief administrator at the school regarding the events. b. Encourage the victimized child to share feelings about the experience. c. Encourage the victimized child to ignore the bullying behavior. d. Discuss the events with the aggressive classmate.

B The behaviors by the bullying child create emotional pain and present the risk for physical pain. The nurse should first listen to the child's complaints and validate the child for reporting the events. Later, school authorities should be notified. School administrators are the most appropriate personnel to deal with the bullying child. The behavior should not be ignored; it will only get worse.

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

C These behaviors are most directly related to impulsivity. Hyperactive behaviors are more physical in nature, such as running, pushing, and the inability to sit. Inattention is demonstrated by failure to listen. Defiance is demonstrated by willfully doing what an authority figure has said not to do.

At the time of a home visit, the nurse notices that each parent and child in a family has his or her own personal online communication device. Each member of the family is in a different area of the home. Which nursing actions are appropriate? Select all that apply. a. Report the finding to the official child protection social services agency. b. Educate all members of the family about risks associated with cyberbullying. c. Talk with the parents about parental controls on the children's communication devices. d. Encourage the family to schedule daily time together without communication devices. e. Obtain the family's network password and examine online sites family members have visited.

B, C, D Education and awareness-based approaches have a chance of effectively reducing harmful online behavior, including risks associated with cyberbullying. Parental controls on the children's devices will support safe Internet use. Family time together will promote healthy bonding and a sense of security among members. There is no evidence of danger to the children, so a report to child protective agency is unnecessary. It would be inappropriate to seek the family's network password and an invasion of privacy to inspect sites family members have visited.

A nurse prepares to lead a discussion at a community health center regarding children's health problems. The nurse wants to use current terminology when discussing these issues. Which terms are appropriate for the nurse to use? Select all that apply. a. Autism b. Bullying c. Mental retardation d. Autism spectrum disorder e. Intellectual development disorder

B, D, E Some dated terminology contributes to the stigma of mental illness and misconceptions about mental illness. It's important for the nurse to use current terminology.

A kindergartener is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to the teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to: a. promote integration of self-concept. b. provide inpatient treatment for the child. c. reduce loneliness and increase self-esteem. d. improve language and communication skills.

C Because of their disruptive behaviors, children with ADHD often receive negative feedback from parents, teachers, and peers, leading to self-esteem disturbance. These behaviors also cause peers to avoid the child with ADHD, leaving the child with ADHD vulnerable to loneliness. The child does not need inpatient treatment at this time. The incorrect options might or might not be relevant.

A nurse will prepare teaching materials for the parents of a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which medication will the information focus on? a. Paroxetine (Paxil) c. Methyphenidate (Ritalin) b. Imipramine (Tofranil) d. Carbamazepine (Tegretol)

C CNS stimulants are the drugs of choice for treating children with ADHD: Ritalin and dexedrine are commonly used. None of the other drugs are psychostimulants used to treat ADHD.

When group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9-year-old in a group that uses: a. guided imagery. b. talk focused on a specific issue. c. play and talk about a play activity. d. group discussion about selected topics.

C Group therapy for young children takes the form of play. For elementary school children, therapy combines play and talk about the activity. For adolescents, group therapy involves more talking.

Which factor presents the highest risk for a child to develop a psychiatric disorder? a. Having an uncle with schizophrenia c. Living with an alcoholic parent b. Being the oldest child in a family d. Being an only child

C Having a parent with a substance abuse problem has been designated an adverse psychosocial condition that increases the risk of a child developing a psychiatric condition. Being in a middle-income family and being the oldest child do not represent psychosocial adversity. Having a family history of schizophrenia presents a risk, but an alcoholic parent in the family offers a greater risk.

Which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective? The child: a. plays with one toy for 30 minutes. b. repeats words spoken by a parent. c. holds the parent's hand while walking. d. spins around and claps hands while walking.

C Holding the hand of another person suggests relatedness. Usually, a child with an autism spectrum disorder would resist holding someone's hand and stand or walk alone, perhaps flapping arms or moving in a stereotyped pattern. The incorrect options reflect behaviors that are consistent with autism spectrum disorders.

A desired outcome for a 12-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) is to improve relationships with other children. Which treatment modality should the nurse suggest for the plan of care? a. Reality therapy c. Social skills group b. Simple restitution d. Insight-oriented group therapy

C Social skills training teaches the child to recognize the impact of his or her behavior on others. It uses instruction, role-playing, and positive reinforcement to enhance social outcomes. The other therapies would have lesser or no impact on peer relationships.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior? a. Increased expressiveness in communication with others b. Abilities to identify anxiety and implement self-control strategies c. Improved abilities to participate in cooperative play with other children d. Tolerates social interactions for short periods without disruption or frustration

C The goal is improvement in the child's hyperactivity, aggression, and play. The remaining options are more relevant for a child with intellectual development disorder or an anxiety disorder.

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

C The most common side effects are gastrointestinal disturbances, reduced appetite, weight loss, urinary retention, dizziness, fatigue, and insomnia. Weight loss has the potential to interfere with the child's growth and development. The distracters relate to side effects of conventional antipsychotic medications.

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 are sudden, rapid, involuntary, repetitive movements or vocalizations characteristic of Tourette's disorder. They often fluctuate in frequency, severity, and are reduced or absent during sleep.

When a 5-year-old is disruptive, the nurse says, "You must take a time-out." The expectation is that the child will: a. go to a quiet room until called for the next activity. b. slowly count to 20 before returning to the group activity. c. sit on the edge of the activity until able to regain self-control. d. sit quietly on the lap of a staff member until able to apologize for the behavior.

C Time-out is designed so that staff can be consistent in their interventions. Time-out may require going to a designated room or sitting on the periphery of an activity until the child gains self-control and reviews the episode with a staff member. Time-out may not require going to a designated room and does not involve special attention such as holding. Counting to 10 or 20 is not sufficient.

A nurse works with a child who is sad and irritable because the child's parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? a. Therapeutic relationships provide an outlet for tension. b. Focusing on the strengths increases a person's self-esteem. c. Acceptance and trust convey feelings of security to the child. d. The child should express feelings rather than internalize them.

C Trust is frequently an issue because the child may question their trusting relationship with the parents. In this situation, the trust the child once had in parents has been disrupted, reducing feelings of security. The correct answer is the most global response.

A nurse prepares the plan of care for a 15-year-old diagnosed with moderate intellectual developmental disorder. What are the highest outcomes that are realistic for this patient? Within 5 years, the patient will: (select all that apply) a. graduate from high school. b. live independently in an apartment. c. independently perform own personal hygiene. d. obtain employment in a local sheltered workshop. e. correctly use public buses to travel in the community.

C, D, E Individuals with moderate intellectual developmental disorder progress academically to about the second grade. These people can learn to travel in familiar areas and perform unskilled or semiskilled work. With supervision, the person can function in the community, but independent living is not likely.

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder? The child: a. has occasional toileting accidents. b. is unable to read children's books. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes.

D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing. Body rocking for extended periods suggests autism spectrum disorder. The distracters are expected findings for a 3-year-old.

The parent of a 6-year-old says, "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for: a. communication disorder. b. stereotypic movement disorder. c. intellectual development disorder. d. attention deficit hyperactivity disorder.

D Excessive motion, distractibility, and excessive talkativeness are seen in attention deficit hyperactivity disorder (ADHD). The behaviors presented in the scenario do not suggest intellectual development, stereotypic, or communication disorder.

Which child demonstrates behaviors indicative of a neurodevelopmental disorder? a. A 4-year-old who stuttered for 3 weeks after the birth of a sibling b. A 9-month-old who does not eat vegetables and likes to be rocked c. A 3-month-old who cries after feeding until burped and sucks a thumb d. A 3-year-old who is mute, passive toward adults, and twirls while walking

D Symptoms consistent with autistic spectrum disorders (ASD) are evident in the correct answer. Autistic spectrum disorder is one type of neurodevelopmental disorder. The behaviors of the other children are within normal ranges.

A 4-year-old cries for 5 minutes when the parents leave the child at preschool. The parents ask the nurse, "What should we do?" Select the nurse's best response. a. "Ask the teacher to let the child call you at play time." b. "Withdraw the child from preschool until maturity increases." c. "Remain with your child for the first hour of preschool time." d. "Give your child a kiss before you leave the preschool program."

D The child demonstrates age-appropriate behavior for a 4-year-old. The nurse should reassure the parents. The distracters are over-reactions.

A child diagnosed with attention deficit hyperactivity disorder had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates the plan of care was effective? The child: a. has an improved ability to identify anxiety and use self-control strategies. b. has increased expressiveness in communication with others. c. shows increased responsiveness to authority figures. d. engages in cooperative play with other children.

D The goal should be directly related to the defining characteristics of the nursing diagnosis, in this case, improvement in the child's aggressiveness and play. The distracters are more relevant for a child with autism spectrum or anxiety disorder.

When a 5-year-old diagnosed with attention deficit hyperactivity disorder (ADHD) bounces out of a chair and runs over and slaps another child, what is the nurse's best action? a. Instruct the parents to take the aggressive child home. b. Direct the aggressive child to stop immediately. c. Call for emergency assistance from other staff. d. Take the aggressive child to another room.

D The nurse should manage the milieu with structure and limit setting. Removing the aggressive child to another room is an appropriate consequence for the aggressiveness. Directing the child to stop will not be effective. This is not an emergency. Intervention is needed rather than sending the child home.