Quiz 2 Practice Questions
Reversible conditions that respond to treatment that may look like Dementia include which of the following? Select all that apply: 1. All of the above 2. None of the above 3. Constipation 4. Urinary Incontinence 5. Fever 6. Hypothyroidism 7. Polypharmacy 8. Dehydration 9. Pseudodementia that is actually depression symptoms 10. Malnutrition related to Anemias
1
Who can do SBIRT and Motivational Interviewing? (choose the best answer) Social Workers and Therapists Anyone with some interest and patience. Nurse Practitioners only Psychotherapists who are specially certified only Nurses who have attended specialty training courses
Anyone with some interest and patience.
A nurse is helping a client's family prepare to have an intervention that hopefully will encourage the alcoholic father to realize the need for change. Which of the following instructions by the nurse to the client's family members would be most effective? Select all that apply: 1. "Express your love and your belief that he can change." 2. "Point out that his behavior is his choice and his responsibility." 3. "Let him know that you understand how much he loves being with his drinking pals and that you agree that their friendship is important." 4. "Remind him that entering treatment is better than going to prison."
1, 2
Violence may occur anywhere in the hospital, but it is most frequent in which areas? (Select all that apply): 1. Psychiatric Units 2. Emergency Departments 3. Waiting Rooms 4. Geriatric Units 5. Outpatient mental health clinics 6. Community health settings 7. Schools
1, 2, 3, 4
Without therapy, the long-term the effects of trauma and violence may include which of the following? (Select all that apply): 1. anger, resentment, fatigue 2. post-traumatic stress disorder (PTSD) 3. depression, insomnia 4. obesity, improper nutrition 5. optimism, hopefulness 6. high productivity
1, 2, 3, 4
Symptoms of withdrawal from opioids for which the nurse should assess include which one of the following list of symptoms? nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. excessive eating, constipation, and headache. dilated pupils, tachycardia, elevated blood pressure, and elation. mood lability, incoordination, fever, and drowsiness.
nausea, vomiting, diaphoresis, anxiety, and hyperreflexia.
A patient diagnosed with an alcohol use 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? "I hear a lot of defensiveness in your voice. Do you really believe this?" "Tell me what happened the last time you drank." "Sooner or later, alcohol will kill you. Then what will happen to your children?" "If you were coping so well, why were you hospitalized again?"
"Tell me what happened the last time you drank."
A client diagnosed with schizophrenia mumbles to the nurse, "I eat skiller. Tend to end. Easter. Boggles. It blows away. Dotter." Which one is the most accurate documentation regarding this client's mental status (MSE) findings? "The client's speech is loose, tangential and circumstantial." "The client's thought content is positive for AH, VH, SI, HI and PI." "The client's thought content is focused on self and other harm." "The client's thought process is disorganized, illogical and incoherent."
"The client's thought process is disorganized, illogical and incoherent."
The nurse can assist a patient to prevent substance use relapse by which of the following? Select all that apply: 1. rehearsing techniques to handle anticipated stressful situations. 2. advising the patient to accept residential treatment if relapse occurs. 3. assisting the patient to identify life skills needed for effective coping. 4. advising isolating self from significant others until sobriety is established. 5. informing the patient of physical changes to expect as the body adapts to functioning without substances.
1, 3, 5
A nurse is applying secondary prevention for a client for Substance Use Disorders (SUDs). Which of the following actions would the nurse most likely complete? Select all that apply: 1. Assist with identifying help or resources. 2. Advise about the need to enter a treatment program. 3. Ask about how relationships with family members and friends have been affected. 4. Assess amount and pattern of use. 5. Use a tool such as the CAGE or MAST scale.
1, 4, 5
Physical assessment of a patient diagnosed with bulimia nervosa (BN) often reveals which of the following? Select all that apply: 1. prominent parotid glands. 2. peripheral edema. 3. thin, brittle hair. 4. 25% underweight. 5. near normal to slightly overweight 6. dental problems 7. GERD 8. cool extremities 9. peripheral neuropathy
1, 5, 6, 7
A client diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The client is aloof, suspicious, and says, "Two staff members I saw talking were plotting to kill me." Based on data gathered at this point, which nursing diagnoses relate? Select all that apply: A. Risk for other-directed violence B. Disturbed thought processes C. Risk for loneliness D. Spiritual distress E. Social isolation
A, B
The purpose of the AIMs scale is to which of the following? Select all that apply: A. To assess involuntary facial, oral, truncal and extremity movements caused by long-term anti-psychotic medication use. B. To monitor clients for evidence of involuntary movements after administration of anti-psychotic medications. C. To assess and monitor for the extrapyramidal medication side effect (EPSE) of akathisia D. To assess and monitor for the side effect of abnormal swallowing E. To assess and monitor for serpentine or choreathetoid movements of the upper arms.
A, B, E
Which one of the following is a consistent conclusion of family violence research?: A. Family violence is perpetuated through generations by a cycle of violence. B. Family violence always involves weapons. C. Family violence rarely occurs in the United States. D. Family violence readily responds to psychiatric medications. E. Family violence is caused primarily from mental illness.
A. Family violence is perpetuated through generations by a cycle of violence.
Cognitive manifestations of a patient in Crisis involve which symptoms? A. Inability to concentrate, problem-solve or make decisions B. anxiety and stress C. sleep problems and nightmares D. stomach problems such as pain, nausea or vomiting
A. Inability to concentrate, problem-solve or make decisions
Which one is the best example of Secondary Prevention for family abuse and violence?: A. calling Child Protective Services (CPS) for a 4 year-old with new onset Chlamydia (Sexually Transmitted Infection, STI). B. teaching children about "good touch" and "bad touch". C. assisting families to develop clear, honest communication patterns. D> teaching new parents what to expect regarding normal child growth and development.
A. calling Child Protective Services (CPS) for a 4 year-old with new onset Chlamydia (Sexually Transmitted Infection, STI).
Signs of "Normal" or Uncomplicated Grief and Loss include which one of the following? Anger, resentment, guilt, withdrawal, hopelessness with some improvement and acceptance of the loss by 6 months. Extended period lasting years of severe somatic complaints. A sudden loss that cannot be shared publicly. A socially unacceptable loss that results in suicidal thoughts.
Anger, resentment, guilt, withdrawal, hopelessness with some improvement and acceptance of the loss by 6 months.
A client was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the case manager learned that the client received a notice of eviction immediately prior to admission. Which one of the following is the nurse case manager's most appropriate action? Determine whether the adverse medication reaction was genuine because the client had nowhere to live. Postpone the client's discharge from the hospital. Contact the landlord who evicted the client to further discuss the situation. Arrange a temporary place for the client to stay until new housing can be arranged.
Arrange a temporary place for the client to stay until new housing can be arranged.
You are a nurse on an inpatient psychiatric unit and observe two patients becoming agitated with one another. The patients start with insults and become increasingly loud and aggressive. There is a clear concern that the verbal altercation may escalate and become physical. As the nurse, your first action should be to do which one of the following?: A. Call for help from the other nurses. B. Allow the patients to work this out on their own because this behavior is a healthy expression of their frustration. C. Attempt to separate the patients. D. Assess the scene to ensure your own safety before approaching the patients.
Assess the scene to ensure your own safety before approaching the patients.
A Community Health Nurse (CHN) would be involved in which of the following activities? Select all that apply: A. Administering blood products to an anemic patient and assess for a transfusion reaction on a medical-surgical unit. B. Identifying vulnerable sub-populations at risk for disease. C. Educating and empowering community members and stakeholders about pertinent health issues. D. Develop disaster plans, advocating for emergency preparedness, and triaging community members involved in a local disaster. E. Performing an emergency room triage assessment of a patient suspected of having a pulmonary embolism.
B, C, D
Which one of the following statements made by a client diagnosed with borderline personality disorder (BPD) indicates the treatment plan is effective? A. "I'm never going to get high on drugs again." B. "I felt empty and wanted to hurt myself, so I called you." C. "I hate my mother. I called her today, and she wasn't home." D. "I think you are the best nurse on the unit."
B. "I felt empty and wanted to hurt myself, so I called you."
Which one of the following scenarios predicts the highest risk for directing violent behavior toward others? A. A client with Obsessive-Compulsive disorder (OCD) who performs daily counting and hand-washing rituals. B. A client with Major Depression with delusions of worthlessness who is worried that others can smell the bad odor emanating from his intact skin. C. A client with Paranoid Delusions who reports feeling afraid of being followed and attacked by others. D. A client who completed alcohol withdrawal 2 weeks ago and is actively attending a rehabilitation program.
C. A client with Paranoid Delusions who reports feeling afraid of being followed and attacked by others.
The parents of a 15-year-old seek to have their teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the client recognizes that these behaviors often occur in which one of the following clients? A. Adolescents who are attention seeking. B. Adolescents who have eating disorders. C. Adolescents who have been abused. D. Adolescents who are developmentally delayed.
C. Adolescents who have been abused.
Which one is the priority intervention for a nurse beginning to work with a client diagnosed with a schizotypal personality disorder? A. Teach the patient how to select clothing for outings. B. Engage the patient in community activities. C. Respect the patient's need for periods of social isolation. D. Prevent the patient from violating the nurse's rights.
C. Respect the patient's need for periods of social isolation.
Which one of the following is the priority nursing diagnosis for a client diagnosed with antisocial personality disorder (ASPD) who has made threats against staff, ripped art off the walls, and thrown objects? A. Impaired social interaction B. Risk for self-directed violence C. Risk for other-directed violence D. Ineffective denial
C. Risk for other-directed violence
When preparing to interview a client diagnosed with narcissistic personality disorder, the nurse would expect to find which one of the following assessment findings? A. preoccupation with minute details; perfectionist. B. charm, drama, seductiveness; seeking admiration. C. grandiosity, low self-esteem, self-importance, and a sense of entitlement. D. difficulty being alone; indecisive, submissiveness.
C. grandiosity, low self-esteem, self-importance, and a sense of entitlement.
The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect to find which one of the following assessment findings? A. attention seeking, melodramatic, and flirtatious. B. impulsive, restless, socially aggressive behavior. C. socially anxious, rambling stories, peculiar ideas. D. arrogant, grandiose, and a sense of self-importance.
C. socially anxious, rambling stories, peculiar ideas.
The nursing care plan for a patient diagnosed with anorexia nervosa (AN) includes the intervention "monitor for complications of re-feeding." Which system should a nurse closely monitor for dysfunction? Cardiovascular Renal Integumentary Dental Endocrine
Cardiovascular
The chart documentation reveals that a newly admitted client is impulsive. The nurse would expect which one of the following behaviors in a client with this history? A. Postponing gratification to an appropriate time. B. Taking responsibility for manipulative behavior. C. Adherence to a strict moral code. D. Acting without thought on urges or desires.
D. Acting without thought on urges or desires.
A client in alcohol rehabilitation reveals to the nurse, "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Which one of the following is the nurse's most important action? A. Respect nurse-patient relationship confidentiality. B. Reply, "I'm glad you feel comfortable talking to me about it." C. File a written report with the agency's ethics committee. D. Anonymously report the abuse by phone to the local child protection agency.
D. Anonymously report the abuse by phone to the local child protection agency. Your patient is not the child so there is no "actual evidence" or even "suspected " abuse of "your patient" to report. You need to maintain the nurse-client relationship (trust-building) and by reporting with your name, you would violate that trust, which may result in the client ending this relationship and your inability to further take care of or advocate for your client. If you report anonymously, (since your patient is the abuser), you may still be able to help the client, and you have still done the appropriate and ethical action in reporting the suspected abuse, while maintaining the therapeutic alliance (trust) and the patient care can continue.
Behavioral signs of a patient in Crisis involve which of the following? A. hyperventilation, shaking or sweating B. inability to concentrate, problem-solve or make decisions C. stomach problems such as pain, nausea or vomiting D. acting impulsively such as driving dangerously or becoming easily angered E. hyperventilating, developing a rash or hives
D. acting impulsively such as driving dangerously or becoming easily angered
Which is one of the best interventions for a patient who has incurred violence? A. share your own personal experiences with the person B. recommend medications for sleep C. watchful waiting, give the person some space to work it out on their own in their own way D. offer empathy and support and an outlet to express general emotions such as journaling E. try to problem-solve for the person
D. offer empathy and support and an outlet to express general emotions such as journaling
Biophysical signs of a patient in Crisis involve which symptoms? A. anxiety and stress B. inability to concentrate, problem-solve or make decisions C. becoming withdrawn and socially isolating oneself D. stomach problems such as pain, nausea or vomiting E. acting impulsively such as driving dangerously
D. stomach problems such as pain, nausea or vomiting
When faced with an irritable, angry and potentially violent patient or colleague, the best tactic is to do which one of the following at that time? A. Be aware that anxiety that escalates to violence is only experienced by fatigued patients. B. Use verbal and physical control tactics yourself to disempower and de-escalate the person yourself. C. Be aware of your verbal and non-verbal communication and impact on others by asking them what they see. D. File a mandatory worker's compensation report and attend required therapy. E. Be self-aware and familiar with your environment, seek help and follow your organization's policies.
E. Be self-aware and familiar with your environment, seek help and follow your organization's policies.
If you cannot defuse a potentially violent situation quickly, what is the highest priority intervention? (The first thing to do...) A. Report any violent incidents to your management. B. Take the patient down. C. Call security for help. D. Ask a patient for help. E. Remove yourself from the situation as quickly as possible.
E. Remove yourself from the situation as quickly as possible.
Which one of the following is the most therapeutic approach for a nurse working with a patient beginning treatment for alcohol addiction? Skeptical, guarded Cool, distant Empathetic, supportive Confrontational
Empathetic, supportive
According to the evidence, motivation to change one's behavior in a positive way is most influenced by which one of the following? hitting 'rock bottom' such as a from a significant crisis legal threats of jail or prison time human connections financial incentives for staying clean and sober court-mandated treatment
Human connections
Which nursing diagnosis is more appropriate for a patient diagnosed with anorexia nervosa (AN) who restricts intake and is 20% below normal weight than for a 130-pound patient diagnosed with bulimia nervosa (BN) who purges? Ineffective coping Imbalanced nutrition: less than body requirements Disturbed body image Powerlessness
Imbalanced nutrition: less than body requirements
Family members who care for elders with cognitive disorders are at risk for caregiver burnout. What is the best nursing intervention to combat this? Offer services and opportunities for respite care. Encourage the family to put the elder family member in a nursing home. Encourage the family to go to family therapy. Assess the family for signs of abuse and neglect and consider removal of the elder from the home.
Offer services and opportunities for respite care.
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? Carotonemia Alopecia Amenorrhea Rosacea Lanugo
Lanugo
A client insistently states, "I can decipher codes of DNA just by looking at someone." Which one of the following problems is most evident? Thought insertion Magical thinking Visual hallucinations (VH) Idea of reference (IOR)
Magical thinking
Which one is the priority nursing intervention when caring for a patient after an overdose of amphetamines? Observe for depression. Monitor vital signs. Awaken the patient every 15 minutes. Use warmers to maintain body temperature.
Monitor vital signs.
Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa (AN) begins to gain weight? Observe for adverse effects of re-feeding. Assess for depression and anxiety. Help the patient balance energy expenditures with caloric intake. Communicate empathy for the patient's feelings.
Observe for adverse effects of re-feeding.
Which medication to maintain abstinence would most likely be prescribed for patients with an addiction to either alcohol or opioids? Bromocriptine (Parlodel) Clonidine (Catapres) Disulfiram (Antabuse) Methadone (Dolophine) Naltrexone (ReVia)
Naltrexone (ReVia)
A client receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The client is diaphoretic. Which one of the following is the nursing best analysis and intervention? Cholestatic jaundice; begin a high-protein, high-cholesterol diet. Agranulocytosis; institute reverse isolation. Tardive dyskinesia (TD); withhold the next dose of medication. Neuroleptic malignant syndrome (NMS); notify health care provider stat.
Neuroleptic malignant syndrome (NMS); notify health care provider stat.
A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which one of the following client needs are the highest priority? Self-actualization Psychosocial Self-esteem Physiological
Physiological
According to the stages of change theory, a person who is currently abusing substances and is in denial of the problem and not ready for change, is in which stage of change? Precontemplative Contemplative stage Planning Stage Resistance stage Action stage
Pre-complative Stages of Change (or Transtheoretical Model of Change) or Prochaska & DiClemente's Change theory: 1. Pre-contemplative (denial, resistant to information) 2. Contemplative (not yet ready to change but more open to listening & hearing about possibilities and benefits of behavioral change) 3. Planning (not yet ready to make actual change but preparing to change at some point) 4. Action (actual behavioral change) 5. Maintenance (has maintained behavioral change for 6 mos or longer) Relapse may occur at any stage.
Which features should be present in a therapeutic milieu for a patient with a hallucinogen overdose? Simple and safe Confrontational and challenging Stimulating and colorful Active and bright
Simple and safe
Which assessment finding for a patient diagnosed with an eating disorder meets criteria for hospitalization? Pulse rate 58 beats/min Serum potassium 3.4 mEq/L Systolic blood pressure 62 mm Hg Urine output 40 mL/hr
Systolic blood pressure 62 mm Hg
A health care provider prescribed depot injections every 3 weeks at the clinic for a chronically psychotic client with a history of medication non-adherence. For this plan to be successful, which one of the following factors will be of critical importance? The attitude of significant others toward the client. Nutrition services in the client's neighborhood. The level of trust between the client and nurse. The availability of transportation to the clinic.
The availability of transportation to the clinic.
What situation associated with a caregiver presents the greatest risk that an older adult will experience abuse by that caregiver? The caregiver is under age 30. The caregiver is a single male relative. The caregiver was neglected as a child. The caregiver has little experience with the elderly.
The caregiver was neglected as a child.
What are true regarding the Mini-Cog and MMSE tools? They are only used in Elders with Cognitive Disorders. They are only used to diagnose cognitive disorders. They are screening tools to assess all stages of cognitive changes over time. They assess emotional functioning. They can differentiate depression and other disorders.
They are screening tools to assess all stages of cognitive changes over time.
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? Pharmacokinetics of the alcohol have changed. Antagonistic effects are evident. Tolerance has developed. Metabolism of the alcohol is now delayed.
Tolerance has developed.
True or False? The primary goal of SBIRT is to identify and effectively intervene with those who are at moderate to high risk for psychosocial or health care problems related to their substance use.
True
True or False? There is almost always a financial impact related to violence due to lost wages, time off work, legal and direct care costs.
True The costs of violence are widespread and impact both the direct costs to treat / care for the victim as well as all of the indirect factors such as lost wages from work absenteeism, life disruptions and generational impact (cycle of violence).
Outpatient treatment is planned for a patient diagnosed with anorexia nervosa (AN). Select the most important desired outcome related to the nursing diagnosis Imbalanced nutrition: less than body requirements. Within 1 week, the patient will do which one of the following? gain 5 to 10 pounds. select clothing that fits properly. limit exercise to less than 2 hours daily. weigh self accurately using balanced scales. gain 1 to 2 pounds.
gain 1 to 2 pounds.
A patient referred to the eating disorders clinic has lost 35 pounds in 3 months. For which physical manifestations of anorexia nervosa (AN) should a nurse assess? Select all that apply: 1. Peripheral edema 2. Parotid swelling 3. Constipation 4. Hypotension 5. Dental caries 6. Lanugo
1, 3, 4, 6
A patient diagnosed with anorexia nervosa (AN) is hospitalized for treatment. What features should the milieu provide? Select all that apply: 1. Flexible mealtimes 2. Unscheduled weight checks 3. Adherence to a selected menu 4. Observation during and after meals 5. Monitoring during bathroom trips 6. Privileges correlated with emotional expression
3, 4, 5
Secondary Prevention of Cognitive Disorders includes which of the following medications? Select all that apply: 1. Cholinesterase Inhibitors such as Aricept or Cognex 2. Symptom Management of agitation, boredom and depression 3. SSRI's 4. Low dose anti-psychotics when warranted for psychosis 5. Screening for cognitive deficits. 6. All of the above.
6.
The AIMs scale is a nursing assessment that observes which of the following? Select all that apply: A. involuntary facial tics B. irregular lip smacking C. purposeless, spontaneous arm and leg movements D. problems with dentures E. involuntary eye brow raising, cheek puffing and chewing movements
A, B, C, E
Which one of the following nursing interventions for clients diagnosed with personality disorders who use manipulation is the most challenging to implement? A. Using aversive therapy. B. Maintaining consistent limits. C. Monitoring suicide attempts. D. Supporting behavioral change
B. Maintaining consistent limits.
Which one is the most correct way to document rape from a date? A. "Client claims she was forced to have sexual intercourse." B. "Client stated that she had intercourse against her will." C. "Client reports, 'My date raped me.' " D. "Client has been sexually assaulted."
C. "Client reports, 'My date raped me.' "
Which personality characteristic is a nurse most likely to assess in a patient diagnosed with anorexia nervosa (AN)? Open displays of emotion Carefree flexibility Rigidity, perfectionism High spirits and optimism
Rigidity, perfectionism
A nurse finds a patient diagnosed with anorexia nervosa (AN) vigorously exercising before gaining the agreed-upon weekly weight. Which response by the nurse is appropriate? "You and I will have to sit down and discuss this problem." "It bothers me to see you exercising. I am afraid you will lose more weight." "According to our agreement, no exercising is permitted until you have gained a specific amount of weight." "Let's discuss the relationship between exercise, weight loss, and the effects on your body."
"According to our agreement, no exercising is permitted until you have gained a specific amount of weight." Behavioral Limit Setting
A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Which is the nurse's best response? "The goal of AA is for members to learn controlled drinking with the support of a higher power." "You will be assigned a sponsor who will plan your treatment program." "An individual is supported by peers while striving for abstinence one day at a time." "You must make a commitment to permanently abstain from alcohol and other drugs."
"An individual is supported by peers while striving for abstinence one day at a time."
An advanced practice nurse uses cognitive-behavioral therapy (CBT) for a patient diagnosed with anorexia nervosa (AN). Which statement by the staff nurse supports this type of therapy? "Being thin doesn't seem to solve your problems. You are thin now but still unhappy." "You seem to feel much better about yourself when you eat something." "It must be difficult to talk about private matters to someone you just met." "What are your feelings about not eating foods that you prepare?"
"Being thin doesn't seem to solve your problems. You are thin now but still unhappy." CBT gently challenges the patient's underlying thinking (automatic errors such as patient has to be perfect or a certain weight to be happy etc) in order to create cognitive dissonance (or an internal conflict) regarding what the patient is doing currently (eating disorder behavior) and the patient's goals (ie. to hold up a mirror to how the behavior doesn't line up with human goals to be happy, out of the hospital, finish school etc...).
A patient diagnosed with anorexia nervosa (AN) virtually stopped eating 5 months ago and 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? "I am fat and ugly." "I'm grossly underweight, but that's what I want." "What I think about myself is my business." "I'm a few pounds overweight, but I can live with it."
"I am fat and ugly."
A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. Boggles. It blows away. Dotter... Get it?" Which one of the following would be the nurse's most therapeutic response? "Your thoughts are very disconnected." "I am having difficulty understanding what you are saying." "Nothing you are saying is clear." "Try to organize your thoughts and then tell me again."
"I am having difficulty understanding what you are saying."
A woman has just delivered a baby and is lamenting that the baby's father is not with her. She shares with you that he became involved with drugs and is now in prison for theft. The new mother says, "It's so sad. He's clearly no good." Which of the following would be the best response by the nurse? "It's good that you and the baby are safe from him." "I'm so sorry to hear that. Is your mother able to be with you?" "You must hate him for leaving you alone with a new baby!" "Is there anyone to help you with the baby until the baby's father can be released and encouraged to get treatment for his addiction?"
"Is there anyone to help you with the baby until the baby's father can be released and encouraged to get treatment for his addiction?"
Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" The nurse's best response is which one? "Use search and destroy tactics to keep the home alcohol free." "Make your loved one responsible for the consequences of behavior." "It's important that you visit your family member on a regular basis." "Alcoholism is a lifelong disease. Relapses are expected."
"Make your loved one responsible for the consequences of behavior."
The spouse of a client diagnosed with schizophrenia says, "I don't understand how events from childhood have anything to do with this disabling illness." Which one of the following nursing responses will best help the spouse understand the cause of this disorder? "It must be frustrating for you that your spouse is sick so much of the time." "Research shows that this condition more likely has a biological basis." "Psychological stress is the basis of most mental disorders." "This illness results from developmental factors rather than stress."
"Research shows that this condition more likely has a biological basis."
A nurse is reviewing with a client the importance of the diabetic diet to maintaining control of blood glucose levels. The client states, "I went to the classes and learned how to count carbohydrates. I have even started to write down what I eat for each meal." Which of the following would be most appropriate response from the nurse? "Now you just have to make sure you don't give that habit up!" "Sounds like you're not ready to really plan your eating yet." "That is great. You've started to take action and make changes." "I'm so glad you're beginning to recognize the need to control your blood sugar."
"That is great. You've started to take action and make changes."
A patient referred to the eating disorders clinic has lost 35 pounds during the past 3 months. To assess eating patterns, the nurse should ask the patient which one? "Do you often feel fat?" "Do you think you eat enough on a daily basis?" "What do you think about your present weight?" "What do you eat in a typical day?" "Who plans the family meals?"
"What do you eat in a typical day?"
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? "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." "It is good that you are supportive of your spouse's sobriety and want to help maintain it." "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." "It will be important for you to structure life to avoid as much stress as you can and provide social protection."
"While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."
Which statement made to a grieving elder demonstrates effective therapeutic communication? "Your loss must be so difficult. I can't imagine how you must be feeling right now." "It must be comforting to know that your loved one is in Heaven with God now." "Life will get better and this too shall pass." "You should light a candle at mass for your loved one." "You can be grateful for the time you had together."
"Your loss must be so difficult. I can't imagine how you must be feeling right now."
Nurses are mandated reporters of which of the following situations? Select all that apply suspected child abuse physical evidence of child abuse a sexually transmitted infection in a child a school-aged child who is dirty, malnourished, and appears to have head lice a thin, elder nursing home resident with multiple bruises and abrasions who will not make eye contact when you ask how he is feeling about his living situation an adult woman who is reluctant to file a report on her female partner who hits her regularly when they are both intoxicated.
1, 2, 3, 4, 5
Which of the following are therapeutic skills to develop and express empathy for a patient? (Select all that apply) 1. Good eye contact 2. Responsive facial expression 3. Active listening body language 4. Verbal and non-verbal "encouragers" such as nodding one's head and saying "Hmm go on." 5. Reflective listening statements like "You are feeling____." 6. Expressing doubt 7. Expressing concern and judgment
1, 2, 3, 4, 5
The CIWA alcohol withdrawal assessment tool assesses the presence of which of the following? (Select all that apply) 1. Nausea/Vomiting 2. Auditory Disturbances 3. Visual Disturbances 4. Tactile Disturbances 5. Diaphoresis 6. Depression 7. Headache 8. Paranoid Ideation 9. Thought Content 10. Short-term memory 11. Anxiety 12. Orientation to person, place, situation
1, 2, 3, 4, 5, 7, 11, 12
Which are the most common risk factors for a patient to become violent? 1. substance use 2. pain 3. head injuries 4. past history of violent behavior 5. being suicidal 6. mandated treatment settings 7. most mentally ill patients 8. specific medical diagnoses
1, 2, 3, 4, 6, 8
According to the Recovery Model of SUDs, the term 'Recovery' means which of the following? For more info, please review to the assigned brief video clip (per the module assignment): https://media.usfca.edu/app/plugin/embed.aspx?ID=-YUBpbSjVEOnwZSxGvBbxgLinks to an external site. (Select all that apply): 1. a process of change through which individuals improve their health and wellness to reach their full potential through a focus on personal responsibility, individual strengths and hope. 2. a non-linear process of change through which individuals are the experts of their experience and strive to live a self-directed life through support and personal empowerment. 3. a process of change through which nurses and health-care professionals play a partner or coaching role. 4. a process of change through which health-care professionals are the experts and instruct, educate and push patients towards healthy choices. 5. a process of change that involves peer support, holistic and person-centered care in an integrated system where nurses collaborate with other disciplines to provide optimal patient care. 6. a process that views the patient with SUDS as a 'mental health problem'. 7. a process that expects that realistically patients will not likely recover fully. 8. a model that allows nurses to discuss patients in private differently than how they would directly address the patient in person.
1, 2, 3, 5
In a Motivational Interviewing approach, readiness for change involves which of the following tools? (Select all that apply) 1. The nurse's use of empathy. 2. A review of the patient's view of the pro's and con's of his/her use. 3. Resolving the patient's ambivalence towards reducing or stopping his/her use of substances. 4. Use of direct confrontation, by calling out the patient's problem with drugs or alcohol. 5. Rolling with the patient's denial and resistance to stop using his/her drug. 6. Developing discrepancy about the patient's current behaviors and what the patient's own goals are.
1, 2, 3, 5, 6
Common side effects of DA-Agonist Drugs to manage Parkinson's Disease include which of the following? Select all that apply: 1. Nausea, Vomiting 2. Dizziness, Orthostasis 3. Upper extremity edema 4. Lower extremity edema 5. Compulsive behaviors such as impulsive shopping, sex, gambling or eating 6. Paranoia 7. Sleep disturbances and behaviors 8. All of the above.
1, 2, 4, 5, 6, 7
A nurse implementing a CIWA-Ar alcohol detox protocol for a patient in alcohol withdrawal will often give which of the following benzodiazepine medications to safely detox the patient? (Select all that apply): 1. Ativan (Lorazepam) 2. Librium (Chlordiazepoxide) 3. Buspar (Buspirone) 4. Lithium (Lithobid) 5. Clozaril (Clozapine) 6. Klonopin (Clonazepam) 7. Valium (Diazepam)
1, 2, 6, 7
A client requests help to stop smoking. Which of the following methods would be the best for the nurse to suggest to the client? Select all that apply: 1. A combination of interventions, beginning with changing the environment . 2. Acupuncture or Chantix alone as monotherapy to reduce the nicotine cravings. 3. Behavior modification through hypnosis with support and possibly medications. 4. Nicotine replacement products such as the Nicotine patch. 5. Wellbutrin (Buproprion, Zyban) with lifestyle modification and support.
1, 3, 4, 5
Non-verbal skills to prevent an already tense situation from increasing include which of the following? (Select all that apply): 1. Project an outwardly calm, confident demeanor with non-threatening eye contact. 2. Smile and keep your hands in your pockets or behind your back. 3. Listen and nod your head to demonstrate that you are paying attention. 4. Respect personal space. Maintain arm/leg distance away from the individual. 5. Approach the patient directly and do vital signs as usual. 6. Approach the patient from an angle or from the side. 7. Verbally tell the patient that you are in control and that they need to listen. 8. All of the above.
1, 3, 4, 6
During the 'Brief Intervention' (BI) of an SBIRT approach to SUDs, the use of Motivational tools includes which of the following? (Select all that apply): 1. A collaborative, compassionate and respectful way of being with the patient. 2. A confrontational approach that assumes that the healthcare professional is the expert. 3. A partnership between the patient and nurse where the nurse tries to understand the patient's experience and perspective. 4. The nurse's use of OARS (open-ended questions, affirmations or statements and reflective listening) to praise positive behaviors and support the person when describing difficult situations. 5. Use of specific techniques to trick the patient into doing what you want them to do. 6. A nurse's support of the patient's skills and strengths. 7. A nurse who establishes rapport with a patient. 8. A nurse who respectfully evokes a patient's thoughts, feelings, concerns, goals and motivations. 9. A nurse who assertively sets the agenda for the patient by telling the patient how drinking is unhealthy and the health risks that it causes.
1, 3, 4, 6, 7, 8
Risk factors for Delirium include which ones? Select all that apply: 1. Use of multiple common medications, drug interactions and side effects 2. Urinary tract infection and/or urinary retention 3. Constipation and/or fecal impaction 4. Dehydration and/or Malnutrition 5. Subdural Hematoma 6. Depression, Delusions, 7. Dementia 8. Seizure states 9. Pneumonia 10. All of the above.
10
Prevention and reduction of workplace violence includes which of the following? (Select all that apply): 1. being aware of noise, the stress of the environment 2. removing objects that can be used as weapons including unnecessary medical equipment 3. being aware of your own body language, biases, behaviors, and voice tone 4. identifying non-verbal patient cures such as looks signifying fear, high anxiety, or a fixed stare 5. being aware of escalating patient behaviors such as heavy breathing, pacing, agitation or clenched fists 6. identification of a patient's behavioral or verbal changes like confusion, neglected hygiene, or a louder voice 7. use of tools such as STAMP (staring/eye contact, tone, anxiety, mumbling, pacing) 8. paying attention to your own countertransference feelings or "6th sense", instincts and intuition with patients. 9. travel with a cell phone when you are out in community settings 10. recognition of any personal abuse history that can influence your own thinking and behaviors 11. all of the above
11
One bed is available on the inpatient eating disorders unit. Which patient should be admitted to this bed? The patient whose weight decreased from__: 110 to 70 pounds over a 4-month period. Vital signs are temperature 36.5° C; pulse, 60 beats/min; blood pressure 80/66 mm Hg 90 to 78 pounds over a 5-month period. Vital signs are temperature, 36.7° C; pulse, 62 beats/min; blood pressure 74/48 mm Hg 120 to 90 pounds over a 3-month period. Vital signs are temperature, 36° C; pulse, 50 beats/min; blood pressure 70/50 mm Hg 150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg
150 to 100 pounds over a 4-month period. Vital signs are temperature, 35.9° C; pulse, 38 beats/min; blood pressure 60/40 mm Hg
Risk factors for Complicated or Dysfunctional Grief and Loss include which of the following? Select all that apply: 1. At the end of life after losing a loved one to a terminal illness 2. Grief that results from an unexpected loss 3. Grief that results from a loss at a young age 4. Grief that results from loss d/t violence or socially unacceptable manner 5. Presence of Pre-existing Mental Health Disorder and a poor social network 6. A survivor who has many interests, hobbies, and future plans 7. A survivor who is independent and interested in making new connections
2, 3, 4, 5
Which of the following are accurate about alcohol withdrawal? (Select all that apply): 1. Signs and symptoms of withdrawal typically begin 4-12 DAYS after alcohol use has stopped or reduced. 2. Withdrawal usually peaks at day two and improves with treatment around days 4-5. 3. Less than 10% develop delirium but it is a risk factor for mortality. 4. Less than 3% develop grand mal seizures but benzodiazepine protocols are used as prophylaxis. 5. Withdrawal protocols are based on symptoms of active withdrawal such as tremors. 6. Clonidine (Catapres) is another common medication used to manage elevated vital signs and withdrawal symptoms.
2, 3, 4, 5, 6
Which of the following are considered examples of violence? (Select all that apply): 1. An elderly confused patient will not eat or take her medications and becomes frustrated saying, "I don't want that poison!" 2. An elderly confused patient who is wandering into other patients rooms at night pushes a nurse who is trying to redirect the patient back to her room. 3. An elderly confused patient calls the nurse an offensive name. 4. A disturbed family member who father died in surgery threatens the nurses and surgeon with bodily harm. 5. An agitated psychotic patient scratches and spits at a nurse who is offering the patient medication. 6. An agitated psychotic patient yells obscenities in the ED waiting room at no one in particular. 7. A fearful psychotic patient lashes out verbally at a nurse who he perceives is trying to harm him. 8. A fearful psychotic patient lashes out with his arms and legs at a nurse who he perceives is trying to harm him. 9. All of the above.
2, 3, 4, 5, 7, 8 General agitation not directed at anyone in particular is not considered violence. Any directed behavior (verbal abuse, verbal threats, or physical actions) towards another (even if the act is not intentional or intended to harm, may be considered violence such as in the example of a confused elder or person who is psychotic who lashes out directly at a nurse in 'self-defense'). The other important concept to consider is that violence is not always physical. It can be psychological, verbal, emotional.
Which of the following include the staff nurse's role in workplace violence prevention? (Select all that apply): 1. writing organizational safety protocols in compliance with OSHA guidelines. 2. recognizing verbal and behavioral cues in others' that may signal stress or violence potential. 3. assess patients' assault, homicidal and suicidal ideation and risks often. 4. attend personal safety training programs by the organization. 5. alert supervisors to any concerns and report all incidents as soon as possible and adherent to organizational procedures. 6. go to work and do your job and only become concerned about an incident if and when it occurs. 7. live your life without being too overly cautious because these incidents rarely happen. 8. avoid wearing overly restrictive or loose clothing, dangly earrings, necklaces, scarves and pony tails. 9. mind your own business and don't get too involved with any "office drama" amongst colleagues who are mean to each other. 10. all of the above
2, 3, 4, 5, 8
A teacher sends a student to the school nurse because the student does not seem to be thinking clearly. The nurse notes that the student is having palpitations, as well as elevated pulse, blood pressure, dizziness and sweating. Active use of which drugs could potentially account for these symptoms? Select all that apply: 1. Alcohol 2. Ecstasy (MDMA) 3. Methylphenidate 4. Marijuana 5. Huffing household cleaning substances
2, 3, 5
Which statements about eating disorders are most accurate? Select all that apply: 1. Individuals with anorexia frequently complain about weight loss. 2. Purging and bulimic behaviors are sometimes associated with anorexia. 3. Most women with bulimia are concerned with the shape and weight of their body. 4. Bulimia is considered to have more medical complications than anorexia and is highest risk. 5. Anorexia is the highest risk of mortality of all psychiatric disorders.
2, 3, 5
A patient undergoing alcohol rehabilitation decides to begin disulfiram (Antabuse) therapy. Patient teaching should include the need to do which of the following? Select all that apply: 1. avoid aged cheeses. 2. avoid alcohol-based skin products. 3. read labels of all liquid medications. 4. wear sunscreen and avoid bright sunlight. 5. maintain an adequate dietary intake of sodium. 6. avoid breathing fumes of paints, stains, and stripping compounds.
2, 3, 6
Anxiety problems in elder adults can manifest as a fear of falling which impact their independence. A CHN doing home care checks on an elder patient with Dementia of Alzheimer's (mild stage) and chronic pain has anxiety related to falling. The nurse would question which new orders? Select all that apply: 1. Encourage yoga and tai-chi as tolerated 2. Xanax 2mg PO QD 3. Fentanyl Transdermal 1 patch Q72 hrs 4. Gabapentin 100mg TID PRN 5. Encourage relaxation techniques 6. Encourage attendance at the adult day 7. health center support groups 8. Order an electric wheelchair
2, 3, 7
An MD has ordered a CIWA-Ar tool (Clinical Institute for the withdrawal from alcohol-revised) to be used as part of an alcohol detoxification protocol. You know that the CIWA-Ar is assessed on a numerical scale. Which of the following are true regarding the CIWA-Ar scale? (Select all that apply) 1. the highest score is 75. 2. the highest score is 67. 3. a score of 0-9 indicates severe withdrawal 4. a score of 0-9 indicates absent or minimal withdrawal 5. the higher the score, the more medication is given 6. a score > 35 indicates a possible transfer to the ICU 7. a patient who receives more than 8 mg of Lorazepam or 5mg of Diazepam in 3 hours is a candidate for ICU level of care. 8. a patient in alcohol withdrawal who receives benzodiazepines should be assessed for respiratory depression. 9. there are 10 parameters that are assessed 10. vital signs are part of the determination about how much medication is given
2, 4, 5, 6, 8, 9, 10
Which of the following is an accurate concern about the use of marijuana? Select all that apply: 1. Marijuana has painful withdrawal symptoms. 2. Marijuana may damage the respiratory tract. 3. Marijuana can often reduce pain but physicians refuse to prescribe it. 4. Marijuana quickly leads to psychological and physiological dependence. 5. Use of Marijuana at a young age is associated with the development of psychotic symptoms.
2, 5
Which of the following statements accurately describes why methadone is used to treat heroin addiction? Select all that apply: 1. Addicts prefer Methadone instead of heroin. 2. Methadone blocks the effects of heroin and reduces the craving. 3. Methadone prevents further dependence on drugs. 4. Methadone gives an enjoyable high, so addicts continue treatment. 5. Methadone is a harm-reduction approach since it is regulated and considered less harmful than street drugs.
2, 5
From a Motivational Interviewing perspective, choose which of the following are the correct use of open-ended questions. (Select all that apply): 1. So, you are here because you are concerned about your alcohol, correct? 2. Tell me, what if anything, concerns you about your alcohol use? 3. Do you agree that you have a problem and it would be a good idea to go into treatment? 4. Do you feel anxious or depressed? 5. Does anyone you know have a problem with your drinking? 6. What do you think you want to do about your drinking? 7. What are some things that you like about smoking marijuana? 8. Tell me about your family and any concerns that they may have. 9. How have you been feeling? 10. What do you think about the possibility of going for treatment?
2, 6, 7, 8, 9, 10
Which of the following are true of the CAGE? (Select all that apply): 1. It is a 5-item screening instrument to determine whether or not a patient should be hospitalized in a 'cage' or locked unit. 2. It is a 4-item screening tool to assess the risk of amphetamine use disorders. 3. It is a 4-item questionnaire to screen for the possibility of alcohol use problems. 4. The screening questions include the client's annoyance regarding others' criticism of their drinking, any efforts made to cut the drinking down, having a morning drink to relieve withdrawal or hangover symptoms and guilt about their alcohol use. 5. The higher the score the less likely the person is an alcoholic. 6. A score of 2 or higher indicates a need for more in-depth screening. 7. C is for Clarity of thinking, A is for Acceptance, G is for Gaining strength & E is for Empowerment.
3, 4, 6
A medical surgical patient is admitted for acute gastritis and you suspect it is related to chronic alcoholism. The patient is currently A &O X 4 but complains of intermittent nausea, moderate anxiety, a moderate headache, and moderate itching/pins and needles sensations in his extremities. The patient appears moderately fidgety and restless and complains of moderate sensitivity to light. You observe obvious diaphoresis on his forehead. He denies any other symptoms. You notice that he has severe tremors of both arms while they are resting on his stomach and his VS are all elevated. Which one would be the most accurate total score assigned for this patient using the CIWA-Ar? 24 34 10 18 40
34 (intermittent nausea (4), severe tremors (7), moderate anxiety (4), moderate agitation (4), obvious paroxysmal sweats (4), A&0 X 4 =orientation (0), tactile disturbances (4), auditory disturbances (0), visual disturbances (3), moderate headache (4). Nausea/vomiting (0 - 7) 0 - none; 1 - mild nausea ,no vomiting; 4 - intermittent nausea; 7 - constant nausea , frequent dry heaves & vomiting. Tremors (0 - 7) 0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/ arms extended; 7 - severe, even w/ arms not extended. Anxiety (0 - 7) 0 - none, at ease; 1 - mildly anxious; 4 - moderately anxious or guarded; 7 - equivalent to acute panic state Agitation (0 - 7) 0 - normal activity; 1 - somewhat normal activity; 4 - moderately fidgety/restless; 7 - paces or constantly thrashes about Paroxysmal Sweats (0 - 7) 0 - no sweats; 1 - barely perceptible sweating, palms moist; 4 - beads of sweat obvious on forehead; 7 - drenching sweat Orientation (0 - 4) 0 - oriented; 1 - uncertain about date; 2 - disoriented to date by no more than 2 days; 3 - disoriented to date by > 2 days; 4 - disoriented to place and / or person Tactile Disturbances (0 - 7) 0 - none; 1 - very mild itch, P&N, ,numbness; 2-mild itch, P&N, burning, numbness; 3 - moderate itch, P&N, burning ,numbness; 4 - moderate hallucinations; 5 - severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous hallucinations Auditory Disturbances (0 - 7) 0 - not present; 1 - very mild harshness/ ability to startle; 2 - mild harshness, ability to startle; 3 - moderate harshness, ability to startle; 4 - moderate hallucinations; 5 severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous.hallucinations Visual Disturbances (0 - 7) 0 - not present; 1 - very mild sensitivity; 2 - mild sensitivity; 3 - moderate sensitivity; 4 - moderate hallucinations; 5 - severe hallucinations; 6 - extremely severe hallucinations; 7 - continuous hallucinations Headache (0 - 7) 0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moderately severe; 5 - severe; 6 - very severe; 7 - extremely severe
A male IDU (injection drug user) admits to the nurse that he has no desire to stop using drugs, so rather than lecture him on the dangers of drug addiction, the nurse counsels him on how to sterilize his needles. Which of the following prevention efforts is the nurse attempting to achieve? Select all that apply: 1. Primary prevention by educating about safe injections. 2. Primary prevention by avoidance of future legal complications. 3. Secondary prevention to reduce the risk for infection or other complications. 4. Tertiary prevention to reduce the transmission of blood-borne diseases. 5. Harm Reduction to minimize complications to the client and community.
4, 5
A patient took a large quantity of the designer drug, 'psychoactive bath salts' (PABS). A nurse is familiar with the risks associated with this street drug. Priority nursing and medical measures include which of the following? Select all that apply: 1. administration of naloxone (Narcan). 2. vitamin B12and folate supplements. 3. restoring nutritional integrity. 4. management of heart rate. 5. environmental safety.
4, 5
A newly admitted client is experiencing acute alcohol withdrawal. The Nurse Practitioner (NP) orders a CIWA (Clinical Institute Withdrawal Assessment). Today is day 1. The client's vital signs are elevated for the first 2 days. Whenever the client has elevated vitals (BP, Resp rate, Pulse & Temp), it is assumed that the Ativan is given. Standing Orders: Give lorazepam (Ativan) 0.5 mg QID (4x/day or every 6hrs) for 5 days. Complete the CIWA Q 4 hours (6x/day) for 5 days with the benzodiazepine detox protocol. Also, give lorazepam (Ativan) PRN Q 4 hours (as per NP orders) based on the following standing orders scale: CIWA score 0-7: 0 mg (Do not give any Ativan PRN) CIWA score 8-15: Give Ativan 0.5mg CIWA score >15: Give Ativan 1.0mg The client's CIWA scores are as follows: Time: Score: 04:00 6 (at admit) 08:00 14 12:00 8 16:00 12 20:00 15 24:00 7 04:00 16 How many total __mg of lorazepam (Ativan) did the client receive in the first day (24hrs)? 8mg 5mg 2mg 3mg 6mg
5mg
Milieu Management for those with Cognitive Disorders such as Dementia include which of the following? Select all that apply: 1. Physical environment aids such as raised bed rails, extra lighting and removal of slip or fall hazards. 2. Maintaining a consistent daily routine with some flexibility in care. 3. Allowing adequate stimulation with activities and safe pacing. 4. Providing memory aids such as clocks and calendars. 5. Keeping a radio on a low level and dim lighting at night. 6. All of the above.
6
Which of the following are considered an Empathic approach by the nurse working with a patient who is using substances? (Select all that apply) 1. The nurse sharing common past experiences with the patient. 2. The nurse giving advice, making suggestions, or providing solutions to the patient. 3. The nurse asking a lot of questions. 4. The nurse's self-disclosure of a personally similar experience with the patient. 5. The nurse agreeing with the patient. 6. The nurse listening and offering statements that reflect an accurate understanding of the patient's experience. 7. The nurse perceiving the patient's experience in a non-judgmental way from the patient's perspective. 8. The nurse understands and reflects back the patient's feelings and words in a warm, supportive manner. 9. Trying to help the patient by pointing out their mistakes and offering suggestions for appropriate solutions.
6, 7, 8
Long-term effects of violence include which of the following? (Select all that apply): 1. low productivity 2. work absences 3. depression and low morale 4. lack of trust in management 5. loss of team cohesion 6. high worker turnover 7. anxiety and stress 8. all of the above
8
An experienced nurse says to a new graduate, "When you've practiced as long as I have, you instantly know how to take care of personality disordered clients." What information should the new graduate consider when analyzing this comment? Select all that apply: A. The experienced nurse may have lost sight of clients' individuality, which may compromise the integrity of practice. B. New research findings should be integrated continuously into a nurse's practice to provide the most effective care. C. Experience provides mental health nurses with the essential tools and skills needed for effective professional practice. D. Experienced psychiatric nurses have learned the best ways to care for mentally ill clients through trial and error. E. An intuitive sense of clients' needs guides effective psychiatric nurses.
A, B
You are the nurse examining a woman who reports that she has a history of being physically, mentally and sexually assaulted by her husband for several years. She is in active recovery. The chart notes a prior history of Rape Trauma Syndrome. She tells you that she is currently living in an emergency shelter to remain safe from him. The shelter address is not listed and she wishes this to be kept in confidence. After the client leaves, you see that the chart also contains signed confidentiality forms allowing her husband access to all of her medical information. What are the bio-ethical nursing actions that would apply to this case? Select all that apply: A. Protect the client's safety and do good by her. Do not give any information to the husband (Beneficence), even if he demands it. B. Do not intentionally harm the client (Non-Maleficence); Follow the intent of her words at her last visit; do not give out any information to her husband under any circumstance. C. The nurse should apply Fidelity to the client. She is your priority not her husband. D. Follow HIPPA and tell the husband the truth (Veracity) if he asks where the shelter is located. E. Respect client's Autonomy; she is on her own now and can handle the husband if he shows up. Follow the intent of the original signed forms and give the husband any information requested.
A, B, C
A public health nurse (PHN) is learning about Community Violence and knows that which of the following are accurate (true) statements? Select all that apply: A. Violence may involve mental pressure or coercion, psychological and physical effects B. The nursing profession is at high risk for violence. C. Risk factors for violence include social isolation, possession of a weapon, substance use disorders, crowded environments and living conditions. D. Inexperienced nurses who set inconsistent boundaries, use force or 'strong-arm' techniques with clients. E. Violence is defined as mainly physical aggression.
A, B, C, D
A client diagnosed with schizophrenia lives in the community. On a home visit, the community nurse case manager learns that the client: • wants to attend an activity group at the mental health outreach center. • is worried about being able to pay for the therapy. • does not know how to get from home to the outreach center. • has an appointment to have blood work at the same time an activity group meets. • wants to attend services at a church that is a half-mile from the patient's home. Which tasks are part of the community mental health nursing role? Select all that apply: A. Rearranging conflicting care appointments. B. Negotiating the cost of therapy for the client. C. Arranging transportation to the outreach center. D. Accompanying the client to church services weekly. E. Monitoring to ensure the client's basic needs are met.
A, C, E
Which of the following are true regarding scoring an AIMs scale? Select all that apply: A. The highest severity observed is rated and scored from 0 (none) to 4 (severe). B. The client may leave their shoes and socks on. C. The client may be assessed sitting or lying down and only the upper body is assessed. D. The higher the score, the more abnormal movements the client is observed to have. E. A lower score means that at present, there are less visible long-term effects from chronic use of anti-psychotics.
A, D, E
A client with psychosis became aggressive, struck another client, and required seclusion. Which one of the following is the most accurate and correct documentation? A. "Client pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 client yelled, "I'll punch anyone who gets near me," and struck another client with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430." B. "Client struck a peer who attempted to leave day room to go to bathroom. Seclusion necessary at 1415. Plan: Maintain seclusion for 8 hours and keep these two clients away from each other for 24 hours." C. "Seclusion ordered by MD for aggressive behavior. Begun at 1415. Maintained for 2 hours without incident. Outcome: Client calmer and apologized for outburst." D. "Seclusion ordered by physician at 1415 after command hallucinations told the client to hit another client. Careful monitoring of client maintained during period of seclusion."
A. "Client pacing, shouting. Haloperidol 5 mg given PO at 1300. No effect by 1315. At 1415 client yelled, "I'll punch anyone who gets near me," and struck another client with fist. Physically placed in seclusion at 1420. Seclusion order obtained from MD at 1430."
The wife of a male client files charges after repeatedly being abused by him. The client sarcastically states, "I am so so so so so sorry for what I did. I so so so so so need psychiatric help." Which one of the client's statements supports an antisocial personality disorder (ASPD) diagnosis? A. "I hit because I am tired of being nagged. My spouse deserves the beating." B. "I feel really terrible about the way my behavior has hurt my family." C. "I have a quick temper, but I can usually keep it under control." D. "I've done some stupid things in my life, and this is one of them, but I've learned a lesson."
A. "I hit because I am tired of being nagged. My spouse deserves the beating."
Limit-setting is a technique that when properly applied can defuse potentially violent and risky situations as well as with challenging or difficult patients in general. Which statement is the best example of appropriate limit-setting with a patient? A. "Mr. Jones, I need for you to bring your voice down so that I can better hear and help you." B. "Mr. Jones, if you don't stop that right now, I am going to put you in restraints!" C. "I cannot believe how terrible you are behaving Mr. Jones. It is really unacceptable." D. "See how I am in control of my behavior? I was hoping that you could watch me and try your best to do the same."
A. "Mr. Jones, I need for you to bring your voice down so that I can better hear and help you."
According to the epidemiological evidence-base regarding risk factors for violence, which one of the following individuals is most at-risk for being involved with violence (as either a perpetrator of violence or as a potential victim)? A. A 19 year old male who currently attends college and has relations to a gang. B. A 78 year old elder man with dementia. C. A 17 year old Caucasian woman who recently separated from her boyfriend. D. A 32 year old woman who is a former gang member and who has been to prison multiple times for vandalism and theft.
A. A 19 year old male who currently attends college and has relations to a gang.
A nurse is conducting an admission interview with Calista, a female client who was raped 2 weeks ago. When asked about the rape, Calista becomes very anxious and upset and begins to sob. Which one of the following nursing actions would be the most therapeutic next course of action? A. Acknowledge that the topic is upsetting and reassure Calista that it can be discussed at another time when she feels more comfortable. B. Use silence as a therapeutic tool and wait until Calista is done sobbing, then continue to discuss the details of what happened during the rape. C. Push Calista gently for more information about the rape details and explain that you need to document them in her chart. D. Reassure Calista that anything she says to you will remain confidential.
A. Acknowledge that the topic is upsetting and reassure Calista that it can be discussed at another time when she feels more comfortable.
Nurses are considered mandated reporters of which of the following? Select all that apply: A. most sexually transmitted infections (STI's) and Communicable Diseases. B. suspected child abuse and neglect even if there are no obvious signs. C. assessment findings of elder neglect and physical abuse. D. a woman who has a specific plan to kill her ex-husband with her car this afternoon. E. all cases of intimate partner violence (IPV) even if the victim does not agree to report abuse.
A. B. C. D. A, B, C, D A. Correct (Nurses are considered mandated reporters of most sexually transmitted infections (STI's) and Communicable Diseases) Every state has a list (your community text) and state and local DPH websites of a list of diseases or syndromes that licensed healthcare providers such as RN's must report. Some common examples include: Zika, Ebola, MRSA, VRSA, Toxic Shock Syndrome (not communicable), Varicella/chicken pox, Measles, Pertussis/ Whooping cough, TB etc. B. Correct (Nurses are considered mandated reporters of suspected child abuse and neglect even if there are no obvious signs). Licensed healthcare providers must advocate, speak up for, and protect those who are dis-empowered or unable to speak for themselves, such as children. We report "suspected" abuse (any type) even when there is no "proof" or obvious or concrete evidence, so that it can be further investigated. We cannot get into trouble so long as we document our suspicions and follow the legal guidelines and organizational protocols for reporting. However, if we miss or do not report appropriately and timely any suspected or obvious abuse or neglect, we can lose our licenses, face fines, civil or even criminal charges/possible jail time. So, the rule is thoroughly document (details, photographs, statements etc) and report report report when in doubt. C. Correct (Nurses are considered mandated reporters of assessment findings of elder neglect and physical abuse). Nurses are mandated to report actual (obvious signs of) elder neglect and physical abuse. The law also encourages reporting of actual findings of emotional/verbal/psychological, fiduciary/financial, sexual abuse, and abandonment and isolation. If you taking care of an elder patient and in your assessment there are signs (objective/observbed) or symptoms (subjective) of sexual abuse, emotional psychological mistreatment, or you gain actual knowledge of any type of abuse (such as from family or victim statements, discovery of bank withdrawals/statements etc), then we should report. D. Correct (Nurses are considered mandated reporters of a woman who has a specific plan to kill her ex-husband with her car this afternoon). This would meet the criteria for a DUTY to Warn or TARASOFF which is mandatory reporting so that the potential victim has the knowledge and opportunity to take necessary safeguards to protect him/herself against this threat. Note: Any person with Homicidal Ideation (HI) who meets the criteria for a specific and imminent plan, with access/means and an intent to carry out the plan, would also meet the criteria for Involuntary Committal under the Lanterman-Petris Act. In the SF Bay Area this is also called a 5150. This statute states that we can take away a person's civil rights to voluntarily leave a locked facility for up to 72 hours in order to keep him or her and others safe. Persons with SI and / or HI with intent, (a specific) plan and means and/or Grave Disability may be committed involuntarily for up to 72 hours. And any person who also specifically has homicidal threats or thinking (ideation) becomes a mandatory reporting to safeguard the potential victim. E. INCORRECT (Nurses are NOT considered mandated reporters of all cases of intimate partner violence (IPV) even if the victim does not agree to report abuse). Some cases of psychological/mental, verbal abuse, physical abuse with no obvious injuries, past physical abuse, fiduciary abuse, and even sexual abuse require an independent adult victim's consent to report. One exception to this rule, when you may report without the victim's consent, is when the patient comes to your healthcare setting seeking direct care for physical or sexual assault injuries and you are providing direct treatment or care of those injuries or insults. In these cases, we may report because an assault or crime has taken place and there is evidence. We thoroughly document including statements, photographic evidence etc to support our report. We document and follow legal and organizational policies for reporting in a timely and accurate manner. If a weapon is involved such as a gunshot wound or stabbing, we can report this to the police without the patient's consent. In all cases, we work with the patient from a Motivational Interviewing format to enhance the likelihood and readiness for the patient to change (ie. leave the abuser, report the abuser etc). We always educate and support the client about abuse and the cycle of violence. We inform them that it is not their fault and they are not to blame for any of it. We offer support and resources and most importantly, prepare an "emergency plan" (such as a "go bag" and shelter information) for IF and when the victim is ready to leave. We need to support patients who do not want to report by NOT reporting in some cases unless they are ready to report, because many victims (and their children) stay with their abuser and we do not want to heighten the risk. When we report IPV, this will often trigger an investigation but many times, there are systemic delays and a lack of protections for the victims so we want to avoid worsening a situation especially when a victim is an independent adult who has rights to make their own life decisions. The exception is adults who are considered "dependent adults" due to having mental, developmental or intellectual disabilities that impair their ability to speak and care for themselves. Nurses would report to speak up for these adults. Dependent Adults Reporting: Nurses are mandated reporters ONLY if in their professional capacity or within the scope of employment (job) provides medical services for a physical condition to patient whom they know OR reasonably suspect has injury that is the result of assaultive or abusive conduct.
A Category V tornado hits a community, destroying many homes and businesses. Which nursing intervention would best demonstrate compassion and caring? (choose one) A. Encouraging persons to describe their memories and feelings about the event. B. Referring a local resident to a community food bank. C. Coordinating psychiatric home care services. D. Arranging transportation to the local community mental health center.
A. Encouraging persons to describe their memories and feelings about the event.
A client diagnosed with borderline personality disorder (BPD) self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to which one of the following? A. Fear of abandonment associated with progress toward autonomy and independence. B. An inherited disorder that manifests itself as an incapacity to tolerate stress. C. Use of projective identification and splitting to bring anxiety to manageable levels. D. A constitutional inability to regulate affect, predisposing to psychic disorganization.
A. Fear of abandonment associated with progress toward autonomy and independence.
A patient on an inpatient locked psychiatric unit is exhibiting violent behavior towards staff. After an attempt to use a de-escalation method, the patient continues to escalate. As a result, it is decided that the patient needs to be put in seclusion and restraints. What do the legal guidelines state in regards to necessary nursing actions once the patient is restrained? (choose one) A. Obtain an MD order for seclusion and restraints, assess the patient every 15 minutes for behavior, vital signs, circulations, and skin assessments. Then document accordingly. B. There are no legal guidelines. Nurses must use their own discretion to decide how to proceed. C. Check on the patient every hour until they have calmed down enough to be released from restraints, document each time the patient is assessed. D. Assess the patient every 15 minutes for behavior, vital signs, circulation, and skin assessments. Then document accordingly.
A. Obtain an MD order for seclusion and restraints, assess the patient every 15 minutes for behavior, vital signs, circulations, and skin assessments. Then document accordingly.
A client diagnosed with borderline personality disorder (BPD) has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should do which one of the following? A. Provide care in a matter-of-fact manner. B. Encourage the patient to express anger. C. Be very rigid and challenging. D. Maintain a stern and authoritarian affect.
A. Provide care in a matter-of-fact manner.
A nurse is working with a family experiencing family violence. Which one of the following rationales best explains why a nurse should be aware of personal feelings while working with this family? A. Strong negative feelings (countertransference) can interfere with assessment, healthy boundaries and clear judgment. B. Positive feelings promote the development of sympathy for clients, which is necessary for good care. C. Strong positive feelings lead to healthy transference with the victim. D. Self-awareness enhances the nurse's advocacy role.
A. Strong negative feelings (countertransference) can interfere with assessment, healthy boundaries and clear judgment.
Which one of the following would a nurse determine to be the most desired outcomes for a client diagnosed with schizotypal personality disorder? A. The client will demonstrate ability to introduce self to a stranger in a social situation. B. The client will report decreased incidence of self-mutilative thoughts. C. The client will demonstrate fewer attempts at splitting or manipulating staff. D. The client will adhere willingly to unit norms.
A. The client will demonstrate ability to introduce self to a stranger in a social situation.
Some characteristics of clients with personality disorders (PD's) make it necessary for staff to schedule frequent team meetings in order to address the client's needs and maintain a therapeutic milieu. Which PD characteristic makes these meetings essential? A. The client's ability to provoke interpersonal conflict. B. The client's flexibility and adaptability to stress C. The client's lack of ability to develop trusting relationships. D. The client's lack of ability to achieve true intimacy.
A. The client's ability to provoke interpersonal conflict.
Which one of the following nursing interventions will best assist a female client to disclose an experience of domestic violence (intimate partner violence, IPV)? A. provide her with a safe, private and non-intimidating environment to communicate in. interview her in the presence of her partner. B. believe and advocate for her only if there are physical signs of trauma. C. allow the client to initiate a discussion on the topic of violence. D. show her a video on domestic violence and spousal abuse and then confront her about her own abuse.
A. provide her with a safe, private and non-intimidating environment to communicate in.
A client took a typical anti-psychotic, trifluoperazine (Stelazine) 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? Agranulocytosis Abnormal Involuntary Movements of Tardive dyskinesia (TD) Antisocial Personality Disorder (ASPD) Tourette's Syndrome
Abnormal Involuntary Movements of Tardive dyskinesia (TD)
Worden's 4 stages of Mourning include which one? Maintaining thoughts of loss as a prominent part of daily thinking Expecting the environment to improve and change Accepting inevitability of the loss
Accepting inevitability of the loss
Which goal for treatment of alcoholism should the nurse address first? Learn about addiction and recovery. Achieve physiologic stability. Develop alternate coping strategies. Develop a peer support system.
Achieve physiologic stability.
A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which one of the following problems is most likely suspected with this client presentation? Acute dystonia/ dystonic reaction Akathisia Tardive dyskinesia (TD) Waxy flexibility Pseudoparkinsonism
Acute dystonia/ dystonic reaction
An acutely violent client diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the client's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which one of the following nursing interventions is indicated? Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record.
Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.
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. Use of which substance is most likely? Amphetamines Heroin Barbiturates Alcohol PCP
Amphetamines
An elder patient with a progressive Cognitive Disorder has difficulty feeding himself despite the fact that he has no motor dysfunction. Which is the correct term to document for this finding? Alexia Agnosia Aphasia Anergia Apraxia
Apraxia
Which nursing intervention has the highest priority for a patient diagnosed with bulimia nervosa (BN)? Explore needs for health teaching. Assess for signs of impulsive eating. Assist the patient to identify triggers to binge eating. Provide corrective consequences for weight loss.
Assist the patient to identify triggers to binge eating.
A novice nurse is assigned to manage the milieu when there is a behavioral crisis with a client in the dining room. The nurse shows a clear understanding of crisis management when he/she does which of the following? Select all that apply: A. The nurse requires that all clients go in their rooms. B. The nurse clears the clients from the dining room to the day room/solarium. C. The nurse encourages the clients to express their reactions to the incident. D. The nurse reassures clients that staff will handle the agitated client. E. The nurse loudly tells all of the clients to "stay out of the way!'"
B, C, D
Which of the following are necessary for a nurse to do in order to effectively assess and deal with a child whom the nurse suspects is being abused? Select all that apply: A. Complete a certification course to work with abused children, otherwise refer the case to the social worker. B. Thoroughly, accurately document, and photograph any signs or symptoms of abuse. C. Be familiar with the common signs and symptoms of abuse and the appropriate reporting agencies in your area. D. Observe and listen to the child and family together as well as separately. E. Report the suspected child abuse to the local child protective services agency.
B, C, D, E
A client in the emergency department says, "Voices say someone is stalking me. They want to kill me because I developed a cure for cancer. I have a knife and will stab anyone who is a threat." Which aspects of the client's mental health have the greatest and most immediate concern to the nurse? Select all that apply: A. Happiness B. Appraisal of reality C. Control over behavior D. Effectiveness in work E. Healthy self-concept
B, C, E
A client diagnosed with schizophrenia had an exacerbation related to medication noncompliance and was hospitalized for 5 days. The client's thoughts are now more organized, and discharge is planned. The client's family says, "It's too soon for discharge. We will just go through all this again." The nurse should do which one of the following? A. Notify hospital security to handle the disturbance and escort the family off the unit. B. Explain that the client will continue to improve if the medication is taken regularly. C. Ask the case manager to arrange a transfer to a long-term care facility. D. Contact the health care provider to meet with the family and explain the discharge rationale.
B. Explain that the client will continue to improve if the medication is taken regularly.
Which one of the following is an appropriate initial outcome for a client diagnosed with a personality disorder (PD) who frequently manipulates others? A.The client will accept the fulfillment of his or her requests within an hour rather than immediately. B. The client will acknowledge manipulative behavior when it is called to his or her attention. C. The client will use manipulation only to get legitimate needs met. D. The client will identify when feeling angry.
B. The client will acknowledge manipulative behavior when it is called to his or her attention.
A nurse reports to the treatment team that a client diagnosed with antisocial personality disorder (ASPD) has displayed the following behaviors: "The client is detached and superficial during counseling sessions". Which one of the following client behaviors most clearly warrants the nurse's limit-setting intervention? A. Detached superficiality during counseling. B. Verbal abuse of another patient. C. Flattering the nurse. D.Lying to other clients.
B. Verbal abuse of another patient.
As the nurse, you suspect that this 6 year old child is being abused. Which one is the correct required time period that the nurse must file a written report? A. Within 24 hours B. Within 36 hours C. Immediately or within the next 2 hours D. Within 48 hours
B. Within 36 hours
Which skill can be used to de-escalate a potentially violent patient in crisis? ignore the behavior and walk away. A. call the police. B. offer an empathic response such as "I understand how upsetting (or frustrating or scary) this must be for you." C. If a patient is constantly complaining, do not bring it up with your supervisor. D. If a patient calls out an error that you made, ignore it and try to move on quickly.
B. offer an empathic response such as "I understand how upsetting (or frustrating or scary) this must be for you."
Three women were brought to the emergency department (ED) by ambulance after a two-car accident at a busy intersection. Which one of these tests should automatically be done under such circumstances? AST, ALT BAL Breathalyzer CPK CBC with diff
BAL
A client says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your patients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? A. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. B. "I'll have to check with your doctor about that; I will get back to you after I do." C. "I understand that you have pain, but giving medicine too soon would not be safe." D. "It would be unsafe to give the medicine early; none of us will do that."
C. "I understand that you have pain, but giving medicine too soon would not be safe."
A client says, "I get into trouble sometimes because I make quick decisions and act on them." Which one of the following is the nurse's most therapeutic response? A. "It sounds as though you've developed some insight into your situation." B. "It's good that you're showing readiness for behavioral change." C. "Let's consider the advantages of being able to stop and think before acting." D. "I bet you have some interesting stories to share about overreacting."
C. "Let's consider the advantages of being able to stop and think before acting."
Which scenario best describes a behavioral crisis? (think safety priority) A. A client is crying hysterically after receiving a phone call from a family member. B. A client is curled up in a corner of the bathroom, wrapped in a towel. C. A client is waving fists, cursing, and shouting threats at a nurse. D. A client is performing push-ups in the middle of the hall, forcing others to walk around.
C. A client is waving fists, cursing, and shouting threats at a nurse.
A 30 year old married male client diagnosed with borderline personality disorder (BPD) has a history of self-mutilation and suicide attempts. The client reveals feelings of emptiness, depression and anger with his life. Which one of the following types of medications would the nurse expect to be prescribed by the Nurse Practitioner (NP)? A. A monoamine oxidase inhibitor (MAOI) like Nardil (Phenelzine) B. A benzodiazepine like Ativan (Lorazepam) C. A mood stabilizing medication like Depakote (Valproic Acid, Depakene) D. A serotonin-norepinephrine reuptake inhibitor (SNRI) like Cymbalta (Duloxetine)
C. A mood stabilizing medication like Depakote (Valproic Acid, Depakene)
Which one is the most important nursing intervention for a potentially violent patient who is currently angry and aggressive? A. Allowing the patient to express themselves. B. Use of pharmacological interventions. C. De-escalation of anger by asking the patient, "What is it that you need?" D. Invading the patient's personal space to ensure the safety of others.
C. De-escalation of anger by asking the patient, "What is it that you need?"
When a client diagnosed with a personality disorder (PD) uses manipulation to get his or her needs met, the staff applies limit-setting interventions. Which one is the most correct rationale for this action? A. It provides an outlet for feelings of anger and frustration. B. It respects the patient's wishes, so assertiveness will develop. C. External controls are necessary due to failure of internal control. D. Anxiety is reduced when staff assumes responsibility for the patient's behavior.
C. External controls are necessary due to failure of internal control.
A 6 year-old child is brought by her parents to the Emergency Department (ED) for a spiral fractured arm. The nurse notices several partially healed scars and bruises over her body. The parents state that she fell off her bicycle and that she is "accident-prone". The chart notes a history of multiple previous injuries since infancy. The most important, nursing action is for the nurse to do is which one of the following? A. Refer the family to their local pediatrician for a referral to Child Protective Services (CPS). B. Observe the family interactions, chart her suspicions in the chart, and ask to see the client again for follow-up. C. Follow the ED procedure for reporting suspected child abuse. D. Ask the child to explain all of her bruises and scars on her body.
C. Follow the ED procedure for reporting suspected child abuse.
A client diagnosed with borderline personality disorder (BPD) was hospitalized several times after self-mutilating episodes. The client remains impulsive. Which one of the following nursing diagnoses is the initial focus of this therapy? A. Powerlessness B. Risk for injury C. Risk for self-directed violence D. Impaired skin integrity
C. Risk for self-directed violence
Which one is the best example of the use of Primary Prevention for family violence?: A. examining the bruises on the skin of an elder nursing home resident who has just returned from a visit at home with his family. B. calling CPS regarding school-aged children who has reported sexual abuse by her father. C. working to eliminate the glamorization of violence in the media. D. counseling a woman living in an abusive relationship about shelter programs.
C. working to eliminate the glamorization of violence in the media.
You, the nurse are assessing a tremulous medical surgical patient who was admitted earlier today for chronic pancreatitis. You notice that the admitting physician forgot to add an important assessment in the chart. Understanding a major cause of pancreatitis, you advocate for which assessment tool to be ordered for this patient? GCS (Glascow Coma Scale) COWS (Clinical Opiate Withdrawal Scale) CIWA-Ar (Clinical Institute for the Withdrawal of Alcohol-revised version) AIMS (Abnormal Involuntary Movement Scale) GDS (Geriatric Depression Scale) SAWS (Severity of Alcohol Withdrawal Scale)
CIWA-Ar (Clinical Institute for the Withdrawal of Alcohol-revised version)
A client diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The client's activities of daily living (ADL's) are severely compromised. Which one of the following outcomes is most appropriate for this client? Client will express positive self-esteem in one month. Client will medicate self by the end of the day. Client will demonstrate increased interest in the environment by the end of week 1. Client will perform self-care activities with coaching by the end of day 3.
Client will perform self-care activities with coaching by the end of day 3.
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 do which one of the following? first treat the schizophrenia, then establish goals for substance abuse treatment. provide long-term care for the patient in a residential facility. withdraw the patient from cannabis, then treat the schizophrenia. Consider each diagnosis primary and provide simultaneous treatment.
Consider each diagnosis primary and provide simultaneous treatment.
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? Place the patient in a vest-type restraint. Obtain a clean-catch urine sample. Force fluids. Consult the health care provider. 5150 the patient.
Consult the health care provider.
A patient who has a substance use disorder and is more open to hearing about the benefits of quitting their substance is in which stage? Planning stage Pre-contemplative stage Maintenance stage Contemplative stage Action stage
Contemplative stage
Three months ago, a client diagnosed with borderline personality disorder (BPD) and a history of self-mutilation began dialectical behavior therapy (DBT). Today, the client phones to say, "I feel empty and want to hurt myself." The nurse should do which one of the following actions? A. Advise the client to take an anti-anxiety medication to decrease the anxiety level. B. Send the client to the crisis intervention unit for 8 to 12 hours. C. Arrange for emergency inpatient hospitalization. D. Assist the client to choose coping strategies for triggering situations.
D. Assist the client to choose coping strategies for triggering situations.
An elderly male client with multi-infarct dementia lashes out and tries to kick people who walk past him in the hallway of a skilled nursing facility. Therapeutic intervention by the nurse should begin by doing which one of the following? A. Directing the patient to cease the behavior. B. Gently touching the patient's arm. C. Asking the patient, "What do you need?" D. Calmly stating to the patient, "This is a safe place."
D. Calmly stating to the patient, "This is a safe place."
While a husband briefly steps out of the exam room to sign forms, the client, his wife states, "I don't know what to do anymore. He doesn't want me to go anywhere while he's at work, not even to visit my sister or friends." Which one of the following nursing diagnoses would the nurse formulate in respect to this data? A. Ineffective Individual Coping related to victimization as evidenced by listening to husband's directions. B. Self-esteem disturbance related to marriage, as evidenced by not being able to leave the house. C. Violence related to abusive husband, as evidenced by victim's statement of fear. D. Powerlessness related to victimization, as evidenced by inability to mobilize a plan of action.
D. Powerlessness related to victimization, as evidenced by inability to mobilize a plan of action.
Which one of the following are signs that an elder may be suffering from the "Neglect" type of elder abuse? A. there have been large cash withdrawals and unusual ATM activity in the elder's bank account. B. the elder has a refusal to go to the same emergency room for repeated physical injuries. C. the elder is uncommunicative and evasive. D. the elder has bed sores, sunken eyes and have lost weight.
D. the elder has bed sores, sunken eyes and have lost weight.
Which statement is true regarding the main differences between Delirium and Dementia? Deliriums are usually reversible if the cause is found but Dementias are never reversible. Delirium usually has an identifiable cause and acute onset while Dementia progresses more slowly. Deliriums only occur in elders while Dementias can occur at any age. Only Delirium is caused by Malnutrition or Polypharmacy (Dementias are not). Delirium progresses slowly and Dementia has a sudden onset.
Delirium usually has an identifiable cause and acute onset while Dementia progresses more slowly.
Kubler-Ross's stages of Grief and Loss include which phases? Depression, Anger, Isolation, Hopelessness, Agreement Sadness, Hopelessness, Agitation, Hopefulness, Acceptance Shock, Disillusionment, Anger, Hope Denial, Anger, Depression, Bargaining, Acceptance
Denial, Anger, Depression, Bargaining, Acceptance
Which assessment findings are likely for an individual who recently injected heroin? Drowsiness, constricted pupils, slurred speech Heightened sexuality, insomnia, euphoria Muscle aching, dilated pupils, tachycardia Anxiety, restlessness, paranoid delusions
Drowsiness, constricted pupils, slurred speech
A new client admits to being sexually coerced and emotionally abused by her live-in boyfriend over the past few years. She states, "We plan to get married next June. Things will be better then. He is always sorry afterwards and I think having a baby will help him to change." Which one of the following is a priority intervention to be included in the nurse's teaching plan? A. Suggest that if she gets pregnant the domestic violence pattern may end. B. Tell her that you, the nurse must report this abuse to the police. C. Support her hope that he will change and supporting her decision to stay in the relationship until they are married. D. Encourage her to enroll in a self-defense class. E. Develop an emergency plan for her since the violence is likely to continue.
E. Develop an emergency plan for her since the violence is likely to continue.
The nurse working with patients with Cognitive Disorders uses a specialized therapeutic and trust-building technique called Reminiscence Therapy. This intervention is characterized by which one? Encouraging residents to talk about pleasurable past events. Playing 'oldies' music from the residents' youth. Telling residents stories about your relatives' past histories. Encouraging residents to make up stories from their past. Reviewing movies that the residents enjoy.
Encouraging residents to talk about pleasurable past events.
A nurse working with a recently admitted patient with Parkinson's Disease knows that the most important advocacy for safety is which one? Ensure that the patient can watch television if bored. Ensure that no anti-psychotics are ordered due to the FDA black box warnings for sudden death and NMS. Ensure that the patient can visit with family members throughout the day and night. Ensure that the patient has soft food diet ordered. Ensure that the patient can take their prescribed medications at the times that best work for the patient.
Ensure that the patient can take their prescribed medications at the times that best work for the patient.
True or False? According to the evidence-based approach, SBIRT (Screening, Brief Intervention & Referral to Treatment) when working with those with substance use disorders (and other problems), there is not much that health care professionals can do until a person is motivated to change.
False (False because motivation is accessible and can be modified or enhanced at many points in the change process. Nurses and other healthcare professionals can access a person's motivation and help move them forward towards positive behavior change well before extensive damage is done to health, relationships, or self-image.)
True or False? Violence only refers to attacks with obvious physical signs and injuries. It never includes verbal or psychological injuries where there is no observable sign(s).
False Violence can be non-physical-- psychological, bullying, intimidation, coercion, emotional, and/or verbal in nature. There may be no obvious physical signs. This is a very important point- to reiterate that violence is not always about physical assault or signs; Violence can absolutely be emotional/psychological and is always about power, coercion and control.
True or False? Violent and an acutely distressed persons are primarily exerting their physical power over another and are often quite in control of their thinking, emotions and behaviors.
False (Violence it is about the misuse of power to control another through physical or emotional manipulation and those who are distressed or in crisis are out of control on the cognitive, behavioral and emotional levels).
True or False? Management and healthcare administration are the only parties who have a responsibility in maintaining a safe work environment, and preventing and responding to violence in the workplace.
False. Nurses and employees are also responsible for understanding and abiding by guidelines, reporting and documenting violence, and not contributing to problems.
Anticipatory Grief is characterized by which one of the following? Grief that occurs after a gradual loss. Grief that occurs due to not being able to publicly share or discuss the loss as a result of it being socially or culturally unacceptable. Grief that occurs before a loss to assist the person in letting go of an imminent loss. Grief that occurs as a reaction to a significant and sudden loss.
Grief that occurs before a loss to assist the person in letting go of an imminent loss.
Disenfranchised Grief is characterized by which one of the following? Grief that occurs due to not being able to publicly share or discuss the loss as a result of it being socially or culturally unacceptable. Grief that occurs after a gradual loss. Grief that occurs before a loss to assist the person in letting go of an imminent loss. Grief that occurs as a reaction to a significant and sudden loss.
Grief that occurs due to not being able to publicly share or discuss the loss as a result of it being socially or culturally unacceptable.
Which of the following approaches has research suggested is the most effective way to approach substance use disorders (SUDs)? Substance abuse education Harm reduction Criminal justice system Punishment approach Zero tolerance
Harm reduction
A patient was diagnosed with anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and lost 25% of body weight. The serum potassium is currently 2.7 mg/dL. Which nursing diagnosis applies? Adult failure to thrive related to abuse of laxatives as evidenced by electrolyte imbalances and weight loss. Disturbed energy field related to physical exertion in excess of energy produced through caloric intake as evidenced by weight loss and hyperkalemia. Ineffective health maintenance related to self-induced vomiting as evidenced by swollen parotid glands and hyperkalemia. Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia.
Imbalanced nutrition: less than body requirements related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia.
A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, "I won't eat until I look thin." Which one is the priority initial nursing diagnosis? Imbalanced nutrition: less than body requirements related to self-starvation Anxiety related to fear of weight gain Ineffective coping related to lack of conflict resolution skills Disturbed body image related to weight loss
Imbalanced nutrition: less than body requirements related to self-starvation
A client diagnosed with schizophrenia has taken a conventional or typical antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? (choose one) Diphenhydramine (Benadryl) Olanzapine (Zyprexa) Chlorpromazine (Thorazine) Haloperidol (Haldol)
Olanzapine (Zyprexa)
A hospitalized patient diagnosed with an alcohol use disorder believes that spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? Keep the room dimly lit. Force fluids. Immediately place physical restraints on the patient. One-on-one supervision. Check the patient every 15 minutes.
One-on-one supervision.
Marie is the head of a large extended family who has early-onset dementia. The best course of action is for the nurse to do which one? Organize a family meeting with the patient's permission to discuss the patient's wishes and introduce the ideas of a healthcare proxy, living will and advanced directives for the family to consider. Ask that the primary provider inform the patient that she is dying and needs to have a living will. Hold a family meeting without the patient. Discuss durable power of attorney with a family member.
Organize a family meeting with the patient's permission to discuss the patient's wishes and introduce the ideas of a healthcare proxy, living will and advanced directives for the family to consider.
Disturbed body image is a nursing diagnosis established for a patient diagnosed with an eating disorder. Which outcome indicator is most appropriate to monitor? Patient expresses satisfaction with body appearance. Weight, muscle, and fat congruence with height, frame, age, and sex. Weight reaches established normal range for the patient. Calorie intake is within required parameters of treatment plan.
Patient expresses satisfaction with body appearance.
A patient diagnosed with anorexia nervosa (AN) 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? Because of increased risk of physical problems with refeeding, the patient's permission is needed. Patient involvement in decision making increases sense of control and promotes compliance with treatment. Because severe anxiety concerning eating is expected, objective and subjective data may be unreliable. A team approach to planning the diet ensures that physical and emotional needs will be met.
Patient involvement in decision making increases sense of control and promotes compliance with treatment.
Which finding constitutes a negative symptom associated with schizophrenia? (choose one) Auditory hallucinations (AH) Hostility Bizarre behavior Poverty of thought
Poverty of thought
At a county board meeting, a nurse reports statistics on drug use in the school. The nurse then requests funding for an after-school recreation program that promotes age-appropriate fun activities and sports. Which of the following objectives is the nurse attempting to meet through this action? Help prevent obesity and boredom. Prevent children from getting in trouble before their parents get home from work. Promote healthy lifestyles with physical activity. Offer alternatives to being "on the streets."
Promote healthy lifestyles with physical activity.
A client diagnosed with schizophrenia has taken fluphenazine (Prolixin) 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which one of the following terms best applies to these symptoms? Pseudoparkinsonism Hepatocellular effects Akathisia Neuroleptic Malignant Syndrome (NMS) Confabulation
Pseudoparkinsonism
A chronically ill client was readmitted when symptoms of the illness exacerbated. The client lives alone and has few outside activities. To best prepare the client for discharge, the nurse will focus on which one of the following actions? Placing the client in a sheltered workshop. Psychoeducation and symptom management to promote medication compliance. Improving client-family relationships. Involving the client in daily visits to a psychosocial club.
Psychoeducation and symptom management to promote medication compliance.
In an SBIRT approach to SUDs, the 'RT' stands for which interventions? 1. Rephrasing Tools 2. Reflective Techniques 3. Referral to Treatment 4. Rolling with ResisTance 5. Reflective Listening
Referral to Treatment
What safety-responsibility does the nurse have in any situation of suspected abuse or neglect? Physically protect the patient from future abuse by the abuser. Arrange for counseling for all involved parties but especially the patient. Inform the suspected abuser that the authorities have been notified. Report the suspected abuse to the proper authorities.
Report the suspected abuse to the proper authorities.
A patient with an antisocial personality disorder (ASPD) was treated several times for substance abuse, but each time the patient relapsed. Which treatment approach is most appropriate? 12-step self-help program Residential program Long-term outpatient therapy 1-week detoxification program
Residential program
A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? Respiratory Neurologic Hepatic Cardiovascular Dermatologic Endocrine
Respiratory
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? Risk for injury Disturbed sensory perception Ineffective denial Ineffective coping
Risk for injury
A school health nurse is asked by a parent group to explain risk factors for Substance Use Disorders (SUDs). Which one of the following information should the nurse include? Persons who use substances are usually women. SUDs are determined primarily by the family environment. SUDs are determined partly by genetic factors. Persons born with fetal alcohol syndrome are alcoholics from birth. Alcoholism is a disease of willpower.
SUDs are determined partly by genetic factors.
A client diagnosed with schizophrenia was discharged 6 months ago and prescribed haloperidol (Haldol). The client now says, "I stopped taking those pills. They made me feel like a robot." The nurse wants to validate the client's experience by describing very common problems with this medication. Which one of the following lists is the most common side effects? Sedation and muscle stiffness Mild fever, sore throat, and skin rash Sweating, nausea, and diarrhea Headache, watery eyes, and runny nose
Sedation and muscle stiffness
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? Verify that security services are immediately available. Obtain a face shield because oral hygiene is poor in methamphetamine abusers. Self-assess personal attitudes, values, and beliefs about this health problem. Perform a thorough assessment of the patient.
Self-assess personal attitudes, values, and beliefs about this health problem.
A nurse prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to an outpatient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop! I don't want to take that medicine anymore. I hate the side effects." Which one of the following is the nurse's best action? Proceed with the injection but explain to the patient that there are medications that will help reduce the unpleasant side effects. Assemble other staff for a show of force and proceed with the injection, using restraint if necessary Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having." Say to the patient, "Since I've already drawn the medication in the syringe, I'm required to give it, but let's talk to the doctor about delaying next month's dose."
Stop the medication administration procedure and say to the patient, "Tell me more about the side effects you've been having."
A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? American Society of Addictions Medicine (ASAM) Institute of Medicine - National Research Council (IOM) National Council of State Boards of Nursing (NCSBN) Substance Abuse and Mental Health Services Administration (SAMHSA)
Substance Abuse and Mental Health Services Administration (SAMHSA)
End of life / GRIEF/ LOSS Dysfunctional or Complicated Grieving is characterized by which of the following signs and symptoms? Progression through the stages of grief and loss without significant problems or prolonged time. Suicidal ideation (SI), difficulty progressing through the grief stages and somatic symptoms lasting greater than 12 months. Mild somatic symptoms such as headaches, nausea, sleep disturbance for less than a year following the loss. Sadness and isolation lasting 3 months.
Suicidal ideation (SI), difficulty progressing through the grief stages and somatic symptoms lasting greater than 12 months.
A client diagnosed with schizophrenia has been stable for 2 months. Today the client's spouse calls the nurse to report the client has not taken prescribed medication and is having disorganized thinking. The client forgot to refill the prescription. The nurse arranges a refill. Which one is the best outcome to add to the plan of care? The client will report to the clinic for medication follow-up every week. The client's spouse will mark dates for prescription refills on the family calendar. The client will call the nurse weekly to discuss medication-related issues. The nurse will obtain prescription refills every 90 days and deliver to the client.
The client's spouse will mark dates for prescription refills on the family calendar.
Students at first-day orientation at the local community college are discussing alcohol and drug abuse with their freshmen advisor. During a break, some students go outside for soft drinks and snacks. Soon after, the advisor walks by and notices several of these students smoking cigarettes. Based on this, which of the following topics of the drug and alcohol orientation would be most important for the advisor to reemphasize after the break? The fact that tobacco smoking causes more deaths than any other behavior in the United States. How to recognize and overcome peer pressure to continue bad habits. A discussion of which drugs are commonly used on campus. How students can learn to "just say no" when offered drugs or drinks.
The fact that tobacco smoking causes more deaths than any other behavior in the United States.
A movie shows a woman and a man having a contest to see who can drink more shots of whiskey. Who is more likely to "win" the drinking contest when the other passes out and cannot continue? If their drinks are the same size, they'll both pass out about the same time. The woman will win because females metabolize alcohol more slowly than men. If they play fair, they'll probably both vomit before passing out. The man will win.
The man will win.
A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behavior by this nurse indicates that additional clinical supervision is needed? The nurse teaches the patient to recognize signs of increasing anxiety and ways to intervene. The nurse's comments to the patient are compassionate and nonjudgmental. The nurse interacts with the patient in a protective fashion. The nurse refers the patient to a self-help group for individuals with eating disorders.
The nurse interacts with the patient in a protective fashion.
A man is addicted to alcohol. In which of the following scenarios is a family member enabling the man to continue drinking? The teenage daughter turns to a favorite teacher for emotional support. The wife asks the nurse to explain why her husband's continued drinking is dangerous. The wife tells her husband's boss that her husband is sick when he is actually inebriated. The son threatens to leave home because he finds the father's behavior embarrassing.
The wife tells her husband's boss that her husband is sick when he is actually inebriated.
When a nurse implements the AIMs scale, she/he knows that the purpose of having a client perform thumb tapping or rapid alternating finger movements is which one of the following? To assess left versus right handed dominance. To assess involuntary facial and leg movements. To assess voluntary fine motor tremors in the fingers. To assess akathisia.
To assess involuntary facial and leg movements.
Elders at the end-of-life who experience clinical depression should be what? Treated with traditional anti-depressants Treated with supportive group therapy and psycho-stimulant medications Treated with ECT and DBS. Not treated as they are experiencing a normal response.
Treated with supportive group therapy and psycho-stimulant medications
Using an SBIRT approach, choose which one from the following examples is the correct first step? Refer the patient to AA Recommend that the patient stop drinking alcohol due to their medical problems. Universally screen all patients in community settings and those who have risks screen further using a validated tool such as the DAST or AUDIT (by the WHO). Listen to the patient Only screen those who admit to using alcohol or drugs.
Universally screen all patients in community settings and those who have risks screen further using a validated tool such as the DAST or AUDIT (by the WHO).
ELDER ABUSE & NEGLECT Signs of suspected elder abuse or neglect that must be reported include which list? An elder who speaks freely with the healthcare provider at appointments about his/her concerns including a sense of grief and sadness related to functional and social losses. Weight gain, clean hygiene, with self-reported interests and hobbies. Weight loss, body odor, unexplained sores or bruising, disinterest, withdrawal, poor eye contact. A full refrigerator, clean home, well-dressed and talkative elder.
Weight loss, body odor, unexplained sores or bruising, disinterest, withdrawal, poor eye contact.
Which list of assessment findings mark the prodromal stage of schizophrenia? (choose one) Auditory hallucinations, ideas of reference, thought insertion, and broadcasting Loose associations, concrete thinking, and echolalia neologisms Stereotyped behavior, echopraxia, echolalia, and waxy flexibility Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
Withdrawal, misinterpreting, poor concentration, and preoccupation with religion
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.Which one is the priority outcome? The patient will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. The patient will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. Within 6 hours, the patient's breath sounds will be clear bilaterally and throughout lung fields. 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.
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.
A newly hospitalized client experiencing psychosis says, "Red chair out town board." Which term should the nurse use to most accurately document this finding? Anhedonia Word salad Echolalia Neologism
Word salad
A hospitalized patient diagnosed with an alcohol use 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 which one of the following? a sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium). the medication, Antabuse (Disulfram). an antipsychotic, such as olanzapine (Zyprexa) or thioridazine (Mellaril). a monoamine oxidase inhibitor antidepressant, such as phenelzine (Nardil). a narcotic analgesic, such as hydromorphone (Dilaudid).
a sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium)
An outpatient diagnosed with anorexia nervosa (AN) has begun re-feeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should do which one of the following? assess lung sounds and extremities. suggest use of an aerobic exercise program. establish a higher goal for weight gain the next week. positively reinforce the patient for the weight gain.
assess lung sounds and extremities.
A nurse provides health teaching for a patient diagnosed with binge-purge bulimia. Priority information the nurse should provide relates to which one of the following? establishing the desired daily weight gain. how to recognize hypokalemia. self-monitoring of daily food and fluid intake. self-esteem maintenance.
how to recognize hypokalemia.
A nursing diagnosis for a patient diagnosed with bulimia nervosa (BN) 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 do which one of the following? identify two alternative methods of coping with loneliness. verbalize two positive things about self. verbalize the importance of eating a balanced diet. appropriately express angry feelings.
identify two alternative methods of coping with loneliness.
An appropriate intervention for a patient diagnosed with bulimia nervosa (BN) who binges and purges is to teach the patient which one of the following? the value of reading journal entries aloud to others. not to skip meals or restrict food. to eat a small meal after purging. to increase oral intake after 4 PM daily.
not to skip meals or restrict food.
A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of which one? promoting processing of anxiety associated with eating. maintaining patients' concentration and attention. shifting the patients' focus from food to psychotherapy focusing on weight control mechanisms and food preparation.
promoting processing of anxiety associated with eating.
Select the priority outcome for a patient completing the fourth alcohol-detoxification program in the past year. Prior to discharge, the patient will do which one of the following? use denial and rationalization in healthy ways. identify constructive outlets for expression of anger. state, "I know I need long-term treatment." develop a trusting relationship with one staff member.
state, "I know I need long-term treatment."
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." Which is the most accurate assessment of this patient? the patient has symptoms of alcohol-withdrawal delirium. the patient may have sustained a head injury before admission. the patient is having an acute psychosis. the patient is attempting to obtain attention by manipulating staff.
the patient has symptoms of alcohol-withdrawal delirium.
A patient is exhibits the following assessment data: skin excoriations, dilated pupils, elevated vital signs, diarrhea, stomach and muscle cramping. Which one is most likely happening with this patient? the patient has an infection related to a staph infection the patient has an infection related to a scabies infection the patient is experiencing methamphetamine withdrawal the patient is experiencing opiate intoxication the patient is experiencing opiate withdrawal the patient is experiencing alcohol intoxication
the patient is experiencing opiate withdrawal
Three months ago a patient diagnosed with binge eating disorder (BED) weighed 198 pounds. Lorcaserin (Belviq) was prescribed. Which one of current assessment finding indicates the need for re-evaluation of this treatment approach? the patient says, "I feel full after eating a small meal." the patient reports problems with dry mouth and constipation. the patient says , "I am using contraceptives." the patient now weighs 196 pounds.
the patient now weighs 196 pounds.
