Study Set 3 (12, 14, 15, 18, 21)

39. A nurse at the mental health clinic plans a series of psychoeducational groups for persons newly diagnosed with schizophrenia. Which two topics take priority? a."The importance of taking your medication correctly" b."How to complete an application for employment" c."How to dress when attending community events" d."How to give and receive compliments" e."Ways to quit smoking"

A,E a."The importance of taking your medication correctly" e."Ways to quit smoking"

123. Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events? a. "I attend my therapy sessions regularly." b. "Those intrusive memories are hidden for a reason and should stay hidden." c. "Keeping busy is the key to getting mentally healthy." d. "I've agreed to move in with my parents so I'll get the support I need."

a. "I attend my therapy sessions regularly."

115. Which assessment finding best supports dissociative fugue? The patient states: a. "I cannot recall why I'm living in this town." b. "I feel as if I'm living in a fuzzy dream state." c. "I feel like different parts of my body are at war." d. "I feel very anxious and worried about my problems."

a. "I cannot recall why I'm living in this town."

157. An older adult is prescribed digoxin (Lanoxin) and hydrochlorothiazide daily as well as lorazepam (Ativan) as needed for anxiety. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the patient's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

a. Drug actions and interactions

167. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior?a. Family therapy b. Bibliotherapy c. Play therapy d. Art therapy

a. Family therapy

112. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

a. Reexperiencing

97.A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." b. Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." c. Say to the wife, "I will call the health care provider to discuss this matter with you." d. Hold the wife's hand in silence until the family arrives.

a. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes."

158. A hospitalized patient diagnosed with delirium misinterprets reality, while a patient diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The patients will: a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

a. remain safe in the environment.

189. Tommy, a 12-year-old boy admitted to the pediatric psychiatric unit, has recently been diagnosed with conduct disorder. In the activity room, the games he wanted to play were already in use. He responded by threatening to throw furniture and to hurt his peers who had the game he wanted. Nancy, a registered nurse, recognizes that Tommy's therapy must include: a. Consistency in implementing the consequences of breaking rules b. Empathetic reasoning when Tommy acts out in the activity room c. Teaching Tommy the benefits of socializing d. Solitary time so that Tommy can think about his actions

b. Empathetic reasoning when Tommy acts out in the activity room

104. A patient diagnosed with depersonalization disorder tells the nurse, "It's starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point? a. Notify the health care provider of this change in the patient's behavior. b. Engage the patient in a physical activity such as exercise. c. Isolate the patient until the sensation has diminished. d. Administer a PRN dose of anti-anxiety medication.

b. Engage the patient in a physical activity such as exercise.

186. Which event experienced in the patient's childhood increases the risk of the development of behaviors associated with intermittent explosive disorder? a. Orphaned at age 4 b. Physically abused from ages 3 to 10 c. Born with a chronic congenital disorder d. One parent was diagnosed with obsessive-compulsive disorder

b. Physically abused from ages 3 to 10

149. A patient diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the patient misinterpreted the telephone ringing. Which problem is this patient experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

d. Agnosia

49. Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply. a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol. c. Administer a medication such as benztropine IM to correct this dystonic reaction. d. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. e. Hold his medication for now and consult his prescriber when he comes to the unit later today.

A,B a. Hold his medication and contact his prescriber. b. Wipe him with a washcloth wet with cold water or alcohol.

40. A patient diagnosed with schizophrenia was hospitalized after arguing with co-workers and threatening to harm them. The patient 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 a.Risk for other-directed violence b.Disturbed thought processes

185. What assessment data would support a diagnosis of conduct disorder? Select all that apply. a. Evidence of social isolation b. Arrested twice for disorderly conduct c. Expresses difficulty in keeping employment d. Demonstrates objective signs of phobia e. Exhibits signs of chronic self-mutilation

A,B,C a. Evidence of social isolation b. Arrested twice for disorderly conduct c. Expresses difficulty in keeping employment

163. Which assessment findings would the nurse expect in a patient experiencing delirium? Select all that apply. a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

A,B,C a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention

82. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a.Offer laxatives if needed. b.Monitor food and fluid intake. c.Provide a quiet sleep environment. d.Eliminate all daily caffeine intake. e.Restrict intake of processed foods.

A,B,C a.Offer laxatives if needed. b.Monitor food and fluid intake. c.Provide a quiet sleep environment.

121. The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

A,B,C,D,E a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels driven to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.

188. When discussing oppositional defiant disorder with a group of parents, what information should the nurse include about the disorder? Select all that apply a. Classic symptoms include anger, irritation, and defiant behavior. b. Children generally outgrow the behaviors without formal treatment. c. Severity is considered mild when symptoms are present in only one setting. d. Disorder is diagnosed equally in both males and females. e. Argumentative and defiant are terms often used to describe the patient.

A,B,C,E a. Classic symptoms include anger, irritation, and defiant behavior. b. Children generally outgrow the behaviors without formal treatment. c. Severity is considered mild when symptoms are present in only one setting. e. Argumentative and defiant are terms often used to describe the patient.

120. A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases.f. minimizing opportunities for exercise and play.

A,B,C,E a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. e. staying with the child until the anxiety decreases.f. minimizing opportunities for exercise and play.

119. A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? Select all that apply. a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder e. Reactive attachment disorder f. Disinhibited social engagement disorder

A,B,D a. Acute stress disorder b. Depersonalization disorder d. Posttraumatic stress disorder

187. What is a common behavior observed in a patient diagnosed with intermittent explosive disorder? Select all that apply. a. Short attention span b. Threatens suicide c. Often purges after eating d. Uses alcohol to excess e. States, "Everyone is out to get me."

A,B,D a. Short attention span b. Threatens suicide d. Uses alcohol to excess

43. To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply. a. Alcohol use disorder b. Major depressive disorder c. Stomach cancer d. Polydipsia e. Metabolic syndrome

A,B,D,E a. Alcohol use disorder b. Major depressive disorder d. Polydipsia e. Metabolic syndrome

162. A patient diagnosed with moderately severe Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the patient's plan of care. Select all that apply. a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. c. Administer anti-anxiety medication before bathing and dressing. d. Provide necessary items and direct the patient to proceed independently. e. If the patient resists dressing, use distraction and try again after a short interval.

A,B,E a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the patient's name and name of the item. e. If the patient resists dressing, use distraction and try again after a short interval.

92. A nurse plans health teaching for a patient with generalized anxiety disorder who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply. a.Caution in use of machinery b.Foods allowed on a tyramine-free diet c.The importance of caffeine restriction d.Avoidance of alcohol and other sedatives e.Take the medication on an empty stomach

A,C,D a.Caution in use of machinery c.The importance of caffeine restriction d.Avoidance of alcohol and other sedatives

81. A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a.Imbalanced nutrition: less than body requirements b.Chronic low self-esteem c.Sexual dysfunction d.Self-care deficit e.Powerlessness f.Insomnia

A,C,D,F a.Imbalanced nutrition: less than body requirements c.Sexual dysfunction d.Self-care deficit e.Powerlessness

181. Select all that apply. A nurse on an adolescent psychiatric unit assesses a newly admitted 14-year-old. An impulse control disorder is suspected. Which aspects of the patient's history support the suspected diagnosis? a. Family history of mental illness b. Allergies to multiple antibiotics c. Long history of severe facial acne d. Father with history of alcohol abuse e. History of an abusive relationship with one parent

A,D,E a. Family history of mental illness d. Father with history of alcohol abuse e. History of an abusive relationship with one parent

83. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply. a.Vital signs b.Urinary frequency c.Psychomotor retardation d.Presence of abdominal pain and diarrhea e.Hyperactivity or feelings of restlessness

A,D,E a.Vital signs d.Presence of abdominal pain and diarrhea e.Hyperactivity or feelings of restlessness

183. Select all that apply.A nurse works with an adolescent who was placed in a residential program after multiple episodes of violence at school. Establishing rapport with this adolescent is a priority because: a. it is a vital component of implementing a behavior modification program. b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. c. the adolescent has demonstrated resistance to other authority figures. d. acceptance and trust convey feelings of security for the adolescent. e. adolescents usually relate better to authority figures than peers.

B,D b. a therapeutic alliance is the first step in a nurse's therapeutic use of self. d. acceptance and trust convey feelings of security for the adolescent.

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

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

122. Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

C,D,E c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

164. Which nursing diagnoses are most applicable for a patient diagnosed with severe Alzheimer's disease? Select all that apply. a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

C,D,E c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

80. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a.Channeling excessive energy b.Reducing guilty ruminations c.Instilling a sense of hopefulness d.Assisting with self-care activities e.Accommodating psychomotor retardation

C,D,E c.Instilling a sense of hopefulness d.Assisting with self-care activities e.Accommodating psychomotor retardation

132. A young child is found wandering alone at a mall. A male store employee approaches and asks where her parents are. She responds, "I don't know. Maybe you will take me home with you?" This sort of response in children may be due to: a. A lack of bonding as an infant b. A healthy confidence in the child c. Adequate parental bonding d. Normal parenting

a. A lack of bonding as an infant

160. An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

a. A list of all medications the person currently takes

100. Which scenario demonstrates a dissociative fugue? a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. b. A man is extremely anxious about his problems and sometimes experiences dazed periods of several minutes passing without conscious awareness of them. c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new restaurants, and complains of "blackouts" despite not drinking. d. A woman reports that when she feels tired or stressed, it seems like her body is not real and is somehow growing smaller.

a. After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing.

41. Which characteristic in an adolescent female is sometimes associated with the prodromal phase of schizophrenia? a. Always afraid another student will steal her belongings. b. An unusual interest in numbers and specific topics. c. Demonstrates no interest in athletics or organized sports. d. Appears more comfortable among males.

a. Always afraid another student will steal her belongings.

146. A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

a. Assist the patient to perform simple tasks by giving step-by-step directions.

153. An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the patient's family? a. Label the bathroom door. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 ml per day.

a. Label the bathroom door.

192. The impulse control spectrum can begin in childhood and continue on into adulthood, often morphing into criminal behaviors. Working with patients diagnosed with these disorders, the best examples of expressed emotion by the nursing staff are: a. Low to prevent emotional reactions b. Matched to the patient's level of emotion c. Flat without evidence of any emotional output d. High expression to improve therapeutic patient emotions

a. Low to prevent emotional reactions

128. A pregnant woman is in a relationship with a male who routinely abuses her. Her unborn child may engage in high-risk behavior as a teen as a result of: a. Maternal stress b. Parental nurturing c. Appropriate stress responses in the brain d. Memories of the abuse

a. Maternal stress

180. Which assessment findings support a diagnosis of oppositional defiant disorder?a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior. b. Exhibits involuntary facial twitching and blinking; makes barking sounds. c. Violates others' rights; cruelty toward people or animals; steals; truancy. d. Displays poor academic performance and reports frequent nightmares.

a. Negative, hostile, and spiteful toward parents. Blames others for misbehavior.

175. Parents of an adolescent diagnosed with a conduct disorder say, "We don't know how to respond when our child breaks the rules in our house. Is there any treatment that might help us?" Which therapy is likely to be helpful for these parents? a. Parent-child interaction therapy (PCIT) b. Behavior modification therapy c. Multi-systemic therapy (MST) d. Pharmacotherapy

a. Parent-child interaction therapy (PCIT)

138. A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

136. What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment

42. Which nursing intervention is particularly well chosen for addressing a population at high risk for developing schizophrenia? a. Screening a group of males between the ages of 15 and 25 for early symptoms. b. Forming a support group for females aged 25 to 35 who are diagnosed with substance use issues. c. Providing a group for patients between the ages of 45 and 55 with information on coping skills that have proven to be effective. d. Educating the parents of a group of developmentally delayed 5- to 6-year-olds on the importance of early intervention.

a. Screening a group of males between the ages of 15 and 25 for early symptoms.

177. An adolescent diagnosed with conduct disorder has aggression, impulsivity, hyperactivity, and mood symptoms. The treatment team believes this adolescent may benefit from medication. The nurse anticipates the health care provider will prescribe which type of medication? a. Second-generation antipsychotic b. Anti-anxiety medication c. Calcium channel blocker d. Beta-blocker

a. Second-generation antipsychotic

CHAPTER 21 165. A 16-year-old diagnosed with a conduct disorder has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.

a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.

148. An older adult patient in the intensive care unit has visual and auditory illusions. Which intervention will be most helpful? a. Using the patient's glasses and hearing aids b. Placing personally meaningful objects in view c. Placing large clocks and calendars on the wall d. Assuring that the room is brightly lit but very quiet at all times

a. Using the patient's glasses and hearing aids

29. A patient diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The term "macnabs" should be documented as: a.a neologism. c.thought insertion. b.concrete thinking. d.an idea of reference

a. a neologism.

CHAPTER 18 133. An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of: a. delirium. b. dementia c. amnestic syndrome. d. Alzheimer's disease.

a. delirium.

117. Relaxation techniques help patients who have experienced major traumas because they: a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.

a. engage the parasympathetic nervous system.

152. Goals of care for an older adult patient diagnosed with delirium caused by fever and dehydration will focus on: a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

a. returning to premorbid levels of function.

101. The nurse who is counseling a patient with dissociative identity disorder should understand that the assessment of highest priority is: a. risk for self-harm. b. cognitive function. c. memory impairment. d. condition of self-esteem.

a. risk for self-harm.

33. A nurse asks a patient diagnosed with schizophrenia, "What is meant by the old saying 'You can't judge a book by looking at the cover.'?" Which response by the patient indicates concrete thinking?a."The table of contents tells what a book is about." b."You can't judge a book by looking at the cover." c."Things are not always as they first appear." d."Why are you asking me about books?"

a."The table of contents tells what a book is about."

18. An acutely violent patient diagnosed with schizophrenia receives several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a.Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. b.Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. c.Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. d.Administer atropine sulfate 2 mg subcut from the PRN medication administration record.

a.Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record.

12. A patient is experiencing delusions of persecution about being poisoned. The patient has refused all hospital meals for 3 days. Which intervention is most likely to be acceptable to the patient?a.Allowing the patient supervised access to food vending machines b.Allowing the patient to phone a local restaurant to deliver meals c.Offering to taste each portion on the tray for the patient d.Providing tube feedings or total parenteral nutrition

a.Allowing the patient supervised access to food vending machines

90. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? a.Altruism c.Intellectualization b.Suppression d.Reaction formation

a.Altruism

17. A patient diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol (Haldol), the patient is calm. Two hours later the nurse sees the patient's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a.An acute dystonic reaction c.Waxy flexibility b.Tardive dyskinesia d.Akathisia

a.An acute dystonic reaction

70. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute?a.January c.June b.April d.September

a.January

67. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?a.Make observations. b.Ask the patient direct questions. c.Phrase questions to require yes or no answers. d.Frequently reassure the patient to reduce guilt feelings.

a.Make observations.

27. The family of a patient diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend?a.Psychoeducational c.Transactional b.Psychoanalytic d.Family

a.Psychoeducational

4. When a patient diagnosed with schizophrenia was discharged 6 months ago, haloperidol (Haldol) was prescribed. The patient now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the patient? a.Sedation and muscle stiffness b.Sweating, nausea, and diarrhea c.Mild fever, sore throat, and skin rashd. d. Headache, watery eyes, and runny nose

a.Sedation and muscle stiffness

69. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective?a.Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b.Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c.Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d.Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

a.Slept 6 hours uninterrupted. Sang with activity group.

54. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a.Social skills training c.Desensitization techniques b.Relaxation training classes d.Use of complementary therapy

a.Social skills training

13. A community mental health nurse wants to establish a relationship with a very withdrawn patient diagnosed with schizophrenia. The patient lives at home with a supportive family. Select the nurse's best plan. a.Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return. b.Arrange to spend 1 hour each day with the patient; focus on asking questions about what the patient is thinking or experiencing; avoid silences. c.Visit twice daily; sit beside the patient with a hand on the patient's arm; leave if the patient does not respond within 10 minutes. d.Visit every other day; remind the patient of the nurse's identity; encourage the patient to talk while the nurse works on reports.

a.Visit daily for 4 days, then every other day for 1 week; stay with patient for 20 minutes, accept silence; state when the nurse will return.

22. What assessment findings mark the prodromal stage of schizophrenia? a.Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b.Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c.Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d.Loose associations, concrete thinking, and echolalia neologisms

a.Withdrawal, misinterpreting, poor concentration, and preoccupation with religion

38. A newly hospitalized patient experiencing psychosis says, "Red chair out town board." Which term should the nurse use to document this finding? a.Word salad c.Anhedonia b.Neologism d.Echolalia

a.Word salad

52. A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a.verbalize realistic positive characteristics about self by (date). b.agree to take an antidepressant medication regularly by (date). c.initiate social interaction with another person daily by (date). d.identify two personal behaviors that alienate others by (date).

a.verbalize realistic positive characteristics about self by (date).

184. Which statement made by a 9-year-old child after hitting a classmate is a typical comment associated with childhood conduct disorder?a. "I'm sorry, I won't hit him again." b. "He deserved it for being a sissy." c. "I didn't think I hit him very hard." d. "He hit me first. You just didn't see it."

b. "He deserved it for being a sissy."

95. After the sudden death of his wife, a man says, "I can't live without her...she was my whole life." Select the nurse's most therapeutic reply. a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

b. "Her death is a terrible loss for you."

108. Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."

b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me."

159. An elderly patient is admitted with delirium secondary to a urinary tract infection. The family asks whether the patient will ever recover. Select the nurse's best response. a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

b. "The confusion will probably get better as we treat the infection."

103. The unlicensed assistive personnel (UAP) says to the nurse, "That patient with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. a. "Spend as much time with her as you can and ask questions about her life." b. "Use short, simple sentences and keep the environment calm and protective." c. "Provide more information about her past to reduce the mysteries that are causing anxiety." d. "Structure her time with activities to keep her busy, stimulated, and regaining concentration."

b. "Use short, simple sentences and keep the environment calm and protective."

144. Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings? a. Huntington's disease b. Alzheimer's Disease c. Parkinson's disease d. Vascular dementia

b. Alzheimer's Disease

137. What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

b. Careful observation and supervision

150. During morning care, a nurse asks a patient diagnosed with dementia, "How was your night?" The patient replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the patient's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

b. Confabulation

190. Some cultures have lower rates of diagnosed conduct disorders than observed in Western societies. The lower rate of incidence may be contributed to: a. Strict parenting with corporal punishment b. Cultural expression of anger as normal behavior c. Parents' limited tolerance for externalizing behavior d. Widespread acceptance of conduct disorders

b. Cultural expression of anger as normal behavior

140. Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntington's disease. Which term unifies these problems? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

b. Dementia

166. A 15-year-old was placed in a residential program after truancy, running away, and an arrest for theft. At the program, the adolescent refused to join in planned activities and pushed a staff member, causing a fall. Which approach by nursing staff will be most therapeutic? a. Planned ignoring b. Establish firm limits c. Neutrally permit refusals d. Coaxing to gain compliance

b. Establish firm limits

CHAPTER 16 93. A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.

b. Explain that the physical symptoms are related to the psychological state.

109. A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination

b. Flashback

106. The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? a. Weight gain b. Flashbacks c. Headache d. Diuresis

b. Flashbacks

155. A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

b. Focus interaction on familiar topics.

145. A patient with stage 3 Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the patient cannot remember what to buy. Which nursing diagnosis applies at this time?a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

b. Impaired memory

151. A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

b. Place locks at the tops of doors.

125. The care plan of a male patient diagnosed with a dissociative disorder includes the nursing diagnosis ineffective coping. Which behavior demonstrated by the patient supports this nursing diagnosis? a. Has no memory of the physical abuse he endured. b. Using both alcohol and marijuana. c. Often reports being unaware of surroundings. d. Reports feelings of "not really being here."

b. Using both alcohol and marijuana.

174. A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support a diagnosis of: a. conduct disorder. b. oppositional defiant disorder. c. intermittent explosive disorder. d. attention deficit hyperactivity disorder.

b. oppositional defiant disorder.

139. Which assessment finding would be likely for a patient experiencing a hallucination? The patient: a. looks at shadows on a wall and says, "I see scary faces." b. states, "I feel bugs crawling on my legs and biting me." c. reports telepathic messages from the television. d. speaks in rhymes.

b. states, "I feel bugs crawling on my legs and biting me."

CHAPTER 12 1. A person has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the person shouts, "They're all plotting to destroy me. Isn't that true?" Select the nurse's most therapeutic response. a."Everyone here is trying to help you. No one wants to harm you." b."Feeling that people want to destroy you must be very frightening." c."That is not true. People here are trying to help you if you will let them." D."Staff members are health care professionals who are qualified to help you."

b."Feeling that people want to destroy you must be very frightening."

79. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a."They will put me to sleep during the procedure so I won't know what is happening." b."I might be a little dizzy or have a mild headache after each procedure." c."I will be unable to care for my children for about 2 months." d."I will avoid eating foods that contain tyramine."

b."I might be a little dizzy or have a mild headache after each procedure."

60. A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a."I really doubt that one person can be blamed for all the bad things that happen." b."Let's look at one bad thing that happened to see if another explanation exists." c."You are being extremely hard on yourself. Try to have a positive focus." d."Are you saying that you don't have any good things happen?"

b."Let's look at one bad thing that happened to see if another explanation exists."

5. Which hallucination necessitates the nurse to implement safety measures? The patient says, a."I hear angels playing harps." b."The voices say everyone is trying to kill me." c."My dead father tells me I am a good person." d."The voices talk only at night when I'm trying to sleep."

b."The voices say everyone is trying to kill me."

53. A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient?a."You look nice this morning." c."I like the shirt you are wearing." b."You're wearing a new shirt." d."You must be feeling better today."

b."You're wearing a new shirt."

73. During a psychiatric assessment, the nurse observes a patient's facial expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? a.Affect depressed; mood flat c.Affect labile; mood euphoric b.Affect flat; mood depressed d.Affect and mood are incongruent.

b.Affect flat; mood depressed

87. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about feelings and concerns. What is the rationale for this intervention? a.Offering hope allays and defuses the patient's anxiety. b.Concerns stated aloud become less overwhelming and help problem solving begin. c.Anxiety is reduced by focusing on and validating what is occurring in the environment. d.Encouraging patients to explore alternatives increases the sense of control and lessens anxiety.

b.Concerns stated aloud become less overwhelming and help problem solving begin.

3. A patient diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this patient perceive the environment? a.Disorganized b.Dangerous c.Supportive d.Bizarre

b.Dangerous

6. A patient's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the patient may be hallucinating? a.Detachment and overconfidence b.Darting eyes, tilted head, mumbling to self c.Euphoric mood, hyperactivity, distractibility d.Foot tapping and repeatedly writing the same phrase

b.Darting eyes, tilted head, mumbling to self

37. A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident?a.Visual hallucinations c.Idea of reference b.Magical thinking d.Thought insertion

b.Magical thinking

63. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve?a.Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b.Mashed potatoes, ground beef patty, corn, green beans, apple pie c.Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d.Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b.Mashed potatoes, ground beef patty, corn, green beans, apple pie

26. A patient diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the patient continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a.Haloperidol (Haldol) c.Chlorpromazine (Thorazine) b.Olanzapine (Zyprexa) d.Diphenhydramine (Benadryl)

b.Olanzapine (Zyprexa)

86. A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate? a.Reassure the patient that all nurses are skilled in providing postoperative care. b.Present the information again in a calm manner using simple language. c.Tell the patient that staff is prepared to promote recovery. d.Encourage the patient to express feelings to family.

b.Present the information again in a calm manner using simple language.

71. A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a.Powerlessness c.Stress overload b.Risk for suicide d.Spiritual distress

b.Risk for suicide

64. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a.Nutrition and hydration b.Supporting physiological stability c.Reducing disorientation and confusion d.Assisting the patient to identify and test negative thoughts

b.Supporting physiological stability

19. A patient took trifluoperazine 30 mg po daily for 3 years. The clinic nurse notes that the patient grimaces and constantly smacks both lips. The patient's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?a.Agranulocytosis c.Tourette's syndrome b.Tardive dyskinesia d.Anticholinergic effects

b.Tardive dyskinesia

35. A client says, "Facebook has a new tracking capacity. If I use the Internet, Homeland Security will detain me as a terrorist." Select the nurse's best initial action. a.Tell the client, "Facebook is a safe website. You don't need to worry about Homeland Security." b.Tell the client, "You are in a safe place where you will be helped." c.Administer a prn dose of an antipsychotic medication. d.Tell the client, "You don't need to worry about that."

b.Tell the client, "You are in a safe place where you will be helped."

11. A nurse observes a catatonic patient standing immobile, facing the wall with one arm extended in a salute. The patient remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon?a.Echolalia c.Depersonalization b.Waxy flexibility d.Thought withdrawal

b.Waxy flexibility

24. A patient diagnosed with schizophrenia begins a new prescription for lurasidone HCL (Latuda). The patient is 5'6" and currently weighs 204 lbs. Which topic is most important for the nurse to include in the teaching plan related to this medication?a.How to recognize tardive dyskinesia c.Ways to manage constipation b.Weight management strategies d.Sleep hygiene measures

b.Weight management strategies

A newly admitted patient diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The patient states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior as: a.echolalia. b.an idea of reference. c.a delusion of infidelity. d.an auditory hallucination.

b.an idea of reference.

57. A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a.dysthymia. c.euphoria. b.anhedonia. d.anergia.

b.anhedonia.

55. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a.distracting the patient from self-absorption. b.careful unobtrusive observation around the clock. c.allowing the patient to spend long periods alone in meditation. d.opportunities to assume a leadership role in the therapeutic milieu.

b.careful unobtrusive observation around the clock.

78. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a.hypotensive shock. c.cardiac dysrhythmia. b.hypertensive crisis. d.cardiogenic shock.

b.hypertensive crisis.

10. A patient diagnosed with schizophrenia demonstrates little spontaneous movement and has waxy flexibility. The patient's activities of daily living are severely compromised. An appropriate outcome would be that the patient will: a.demonstrate increased interest in the environment by the end of week 1. b.perform self-care activities with coaching by the end of day 3. c.gradually take the initiative for self-care by the end of week 2. d.accept tube feeding without objection by day 2.

b.perform self-care activities with coaching by the end of day 3.

171. An adolescent acts out in disruptive ways. When this adolescent threatens to throw a pool ball at another adolescent, which comment by the nurse would set appropriate limits? a. "Attention everyone: we are all going to the craft room." b. "You will be taken to seclusion if you throw that ball." c. "Do not throw the ball. Put it back on the pool table." d. "Please do not lose control of your emotions."

c. "Do not throw the ball. Put it back on the pool table."

129. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states: a. "I understand that imaginary friends are abnormal." b. "I understand that imaginary friends are a maladaptive behavior." c. "I understand that imaginary friends are a coping mechanism." d. "I understand that we should tell the child that imaginary friends are unacceptable."

c. "I understand that imaginary friends are a coping mechanism."

An adolescent was recently diagnosed with oppositional defiant disorder. The parents say to the nurse, "Isn't there some medication that will help with this problem?" Select the nurse's best response. a. "There are no medications to treat this problem. This diagnosis is behavioral in nature." b. "It's a common misconception that there is a medication available to treat every health problem." c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d. "There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you."

c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use."

193. Claude is a new nurse on the psychiatric unit. He asks a senior nurse on staff for the "best advice" when working with oppositional defiant disorder. Which statement reflects advice on solid therapeutic communication? a. "When correcting behavior, use a loud firm tone." b. "Use language beyond the patient's education level." c. "When setting limits, be specific and outline consequences." d. "An aggressive body language will make the patients respect your position."

c. "When setting limits, be specific and outline consequences."

47. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes? a. "I know you say you hear voices, but I cannot hear them." b. "Stop listening to the voices, they are NOT real." c. "You say you hear voices, what are they telling you?" d. "Please tell the voices to leave you alone for now."

c. "You say you hear voices, what are they telling you?"

170. An 11-year-old diagnosed with oppositional defiant disorder becomes angry over the rules at a residential treatment program and begins cursing at the nurse. Select the best method for the nurse to defuse the situation. a. Ignore the child's behavior. b. Send the child to time-out. c. Accompany the child to the gym and shoot baskets. d. Role-play a more appropriate behavior with the child.

c. Accompany the child to the gym and shoot baskets.

131. During a routine health screening, a grieving widow whose husband died 15 months ago reports emptiness, a loss of self, difficulty thinking of the future, and anger at her dead husband. The nurse suggests bereavement counseling. The widow is most likely suffering from: a. Major depression b. Normal grieving c. Adjustment disorder d. Posttraumatic stress disorder

c. Adjustment disorder

142. An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

c. Agnosia

96.A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? a. The comment suggests potential allegations of malpractice. b. In some cultures, grief is expressed solely through anger. c. Anger is an expected emotion in an adjustment disorder. d. The patient had ambivalent feelings about her husband.

c. Anger is an expected emotion in an adjustment disorder.

50. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with: a. Generally good health despite the mental illness. b. An aversion to drinking fluids. c. Anxiety and depression. d. The ability to express his needs. c. Anxiety and depression.

c. Anxiety and depression.

113. A soldier who served in a combat zone returned to the U.S. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis

c. Avoidance

161. A nurse gives anticipatory guidance to the family of a patient diagnosed with stage 3, mild cognitive decline Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

c. Communication deficits

102. A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? a. Acute stress disorder b. Dissociative amnesia c. Depersonalization disorder d. Disinhibited social engagement disorder

c. Depersonalization disorder

126. Which statement accurately describes the effects of emotional trauma on the individual physically? a. Emotional trauma is a distinct category and unrelated to physical problems b. The physical manifestations of emotional trauma are usually temporary c. Emotional trauma is often manifested as physical symptoms d. Patients are more aware of the physical problems caused by trauma

c. Emotional trauma is often manifested as physical symptoms

124. Which goal should be addressed initially when providing care for 10-year-old Harper who is diagnosed with posttraumatic stress disorder (PTSD)? a. Harper will be able to identify feelings through the use of play therapy. b. Harper and her parents will have access to protective resources available through social services. c. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts. d. Harper and her parents will demonstrate an understanding of the personal human response to traumatic events.

c. Harper will demonstrate the effective use of relaxation techniques to restore a sense of control over disturbing thoughts.

173. Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, "I'd rather stay in my room and listen to music. It's easier than thinking about what is happening in my family." Which nursing diagnosis is most applicable?a. Chronic low self-esteem related to role within the family b. Decisional conflict related to compliance with school requirements c. Ineffective coping related to adjustment to changes in family relationships d. Disturbed personal identity related to self-perceptions of changing family dynamics

c. Ineffective coping related to adjustment to changes in family relationships

168. An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which nursing diagnosis is most applicable? a. Disturbed personal identity related to acting out as evidenced by prostitution b. Hopelessness related to achievement of role identity as evidenced by feeling unloved by parents c. Ineffective coping related to inappropriate methods of seeking parental attention as evidenced by acting out d. Impaired parenting related to inequitable feelings toward children as evidenced by showing preference for one child over another

c. Ineffective coping related to inappropriate methods of seeking parental attention as evidenced by acting out

141. Which medication prescribed to patients diagnosed with Alzheimer's disease antagonizes N-Methyl-D-Aspartate (NMDA) channels rather than cholinesterase? a. Donepezil (Aricept) b. Rivastigmine (Exelon) c. Memantine (Namenda) d. Galantamine (Razadyne)

c. Memantine (Namenda)

143. An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Preclinical Alzheimer's disease b. Mild cognitive decline c. Moderately severe cognitive decline d. Severe cognitive decline

c. Moderately severe cognitive decline

179. An adolescent diagnosed with a conduct disorder stole and wrecked a neighbor's motorcycle. Afterward, the adolescent was confronted about the behavior but expressed no remorse. Which variation in the central nervous system best explains the adolescent's reaction? a. Serotonin dysregulation and increased testosterone activity impair one's capacity for remorse. b. Increased neuron destruction in the hippocampus results in decreased abilities to conform to social rules. c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy. d. Disturbances in the occipital lobe reduce sensations that help an individual clearly visualize the consequences of behavior.

c. Reduced gray matter in the cortex and dysfunction of the amygdala results in decreased feelings of empathy.

147. Two patients in a residential care facility have dementia. One shouts to the other, "Move along, you're blocking the road." The other patient turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both patients. b. Reinforce reality. Say to the patients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the patients. Take one to the day room and the other to an activities area. d. Step between the two patients and say, "Please quiet down. We do not allow violence here."

c. Separate and distract the patients. Take one to the day room and the other to an activities area.

105. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch fire. Which division of the autonomic nervous system will be stimulated in response to this experience? a. Limbic system b. Peripheral nervous system c. Sympathetic nervous system d. Parasympathetic nervous system

c. Sympathetic nervous system

134. A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the patient experiencing? a. Aphasia b. dystonia c. Tactile hallucinations d. Mnemonic disturbance

c. Tactile hallucinations

107. A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for: a. bipolar disorder. b. schizophrenia. c. depression. d. dementia

c. depression.

116. After major reconstructive surgery, a patient's wounds dehisced. Extensive wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: a. pons. b. occipital lobe. c. hippocampus. d. hypothalamus.

c. hippocampus.

15. A newly admitted patient diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a."Do you hear the voices often?" b."Do you have a plan for getting away from the voices?" c."I'll stay with you. Focus on what we are talking about, not the voices. " d."Forget the voices and ask some other patients to play cards with you."

c."I'll stay with you. Focus on what we are talking about, not the voices. "

68. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: a."Go to the nearest emergency department immediately." b."Do not to be alarmed. Take two aspirin and drink plenty of fluids." c."Take a dose of your antidepressant now and come to the clinic to see the health care provider." d."Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c."Take a dose of your antidepressant now and come to the clinic to see the health care provider."

9. A patient diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates waxy flexibility. Which patient needs are of priority importance? a.Self-esteem c.Physiological b.Psychosocial d.Self-actualization

c.Physiological

21. The nurse assesses a patient diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia?a.Auditory hallucinations c.Poor personal hygiene b.Delusions of grandeur d.Psychomotor agitation

c.Poor personal hygiene

36. Which finding constitutes a negative symptom associated with schizophrenia? a.Hostility c.Poverty of thought b.Bizarre behavior d.Auditory hallucinations

c.Poverty of thought

16. A patient 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 term applies to these symptoms?a.Neuroleptic malignant syndrome c.Pseudoparkinsonism b.Hepatocellular effects d.Akathisia

c.Pseudoparkinsonism

89. A person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety?a.Mild c.Severe b.Moderate d.Panic

c.Severe

66. Major depression resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies?a.Powerlessness c.Situational low self-esteem b.Defensive coping d.Disturbed personal identity

c.Situational low self-esteem

91. A patient experiencing panic suddenly began running and shouting, "I'm going to explode!" Select the nurse's best action. a.Ask, "I'm not sure what you mean. Give me an example." b.Capture the patient in a basket-hold to increase feelings of control. c.Tell the patient, "Stop running and take a deep breath. I will help you." d.Assemble several staff members and say, "We will take you to seclusion to help you regain control."

c.Tell the patient, "Stop running and take a deep breath. I will help you."

77. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a.Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b.Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c.Temporary memory impairments and confusion may occur with electroconvulsive therapy. d.The patient needs time to readjust to a pressured work schedule.

c.Temporary memory impairments and confusion may occur with

56. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a.psychoanalytic therapy. b.desensitization therapy. c.cognitive behavioral therapy. d.alternative and complementary therapies.

c.cognitive behavioral therapy.

75. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: a.discuss with the health care provider the need to increase the dose. b.reassure the patient that the medication will be effective soon. c.explain the time lag before antidepressants relieve symptoms. d.critically assess the patient for symptoms of improvement.

c.explain the time lag before antidepressants relieve symptoms.

62. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a.restricting sodium intake to 1 gram daily. b.minimizing exposure to bright sunlight. c.reporting increased suicidal thoughts. d.maintaining a tyramine-free diet.

c.reporting increased suicidal thoughts.

58. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a.limit the patient's activities to those that can be performed in a sitting position. b.withhold the drug, force oral fluids, and notify the health care provider. c.teach the patient strategies to manage postural hypotension. d.update the patient's mental status examination.

c.teach the patient strategies to manage postural hypotension.

72. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a.Tomato juice c.Hot tea b.Orange juice d.Milk

d.Milk

135. A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

154. A older patient diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this patient recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

d. "It is disappointing when someone you love no longer recognizes you."

114. A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

99. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. a. "Are you taking your medications the way they are prescribed?" b. "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" c. "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

d. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

130. An incest survivor undergoing treatment at the mental health clinic is relieved when she learns that her anxiety and depression are: a. Going to be eradicated with treatment b. Normal and will soon pass c. Abnormal but will pass d. A normal reaction to posttraumatic events

d. A normal reaction to posttraumatic events

127. The school nurse has been alerted to the fact that an 8-year-old boy routinely playacts as a police officer "locking up" other children on the playground to the point where the children get scared. The nurse recognizes that this behavior is most likely an indication of: a. The need to dominate others b. Inventing traumatic events c. A need to develop close relationships d. A potential symptom of traumatization

d. A potential symptom of traumatization

172. The family of a child diagnosed with an impulse control disorder needs help to function more adaptively. Which aspect of the child's plan of care will be provided by an advanced practice nurse rather than a staff nurse?a. Leading an activity group b. Providing positive feedback c. Formulating nursing diagnoses d. Dialectical behavioral therapy (DBT)

d. Dialectical behavioral therapy (DBT)

191. Larry, a middle-aged male in a treatment facility, is loudly displaying anger in the day room with a visiting family member. It is obvious to the nurse this pattern has played out before. Violence is often escalated when family members or authority figures: a. Use a soft tone of voice to gain control of the situation b. Move away from the agitated person in fear c. Use simple words to communicate d. Engage in a power struggle

d. Engage in a power struggle

110/A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th

d. Fireworks display on July 4th

176. An adolescent diagnosed with an impulse control disorder said, "I just want to die. I spend all my time getting even with people who have done wrong to me." When asked about a suicide plan, the adolescent replied, "I'll jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldn't swim." Rate the suicide risk. a. Absent b. Low c. Moderate d. High

d. High

156. What is the priority need for a patient with late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the patient from wandering d. Maintenance of nutrition and hydration

d. Maintenance of nutrition and hydration

45. Which characteristic presents the greatest risk for injury to others by the patient diagnosed with schizophrenia? a. Depersonalization b. Pressured speech c. Negative symptoms d. Paranoia

d. Paranoia

111. A soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? a. Immediately upon return to the U.S. from Afghanistan b. Before departing Afghanistan to return to the U.S. c. One year after returning from Afghanistan d. Screening should be on-going

d. Screening should be on-going

44. A female patient diagnosed with schizophrenia has been prescribed a first-generation antipsychotic medication. What information should the nurse provide to the patient regarding her signs and symptoms? a. Her memory problems will likely decrease. b. Depressive episodes should be less severe. c. She will probably enjoy social interactions more. d. She should experience a reduction in hallucinations.

d. She should experience a reduction in hallucinations.

48. When patients diagnosed with schizophrenia suffer from anosognosia, they often refuse medication, believing that: a. Medications provided are ineffective. b. Nurses are trying to control their minds. c. The medications will make them sick. d. They are not actually ill.

d. They are not actually ill.

46. Gilbert, age 19, is described by his parents as a "moody child" with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered: a. Favorable with medication b. In the relapse stage c. Improvable with psychosocial interventions d. To have a less positive outcome

d. To have a less positive outcome

118. Select the correct etiology to complete this nursing diagnosis for a patient with dissociative identity disorder. Disturbed personal identity related to: a. obsessive fears of harming self or others. b. poor impulse control and lack of self-confidence. c. depressed mood secondary to nightmares and intrusive thoughts. d. cognitive distortions associated with unresolved childhood abuse issues.

d. cognitive distortions associated with unresolved childhood abuse issues.

169. A 12-year-old has engaged in bullying for several years. The parents say, "We can't believe anything our child says." Recently this child shot a dog with a pellet gun and set fire to a neighbor's trash bin. The child's behaviors support the diagnosis of: a. attention deficit hyperactivity disorder. b. intermittent explosive disorder. c. defiance of authority. d. conduct disorder.

d. conduct disorder.

94. Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: a. visit their teenager's grave daily. b. return immediately to employment. c. discuss the accident within the family only. d. create a scholarship fund at their child's high school.

d. create a scholarship fund at their child's high school.

98.A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents: a. visit their child's grave daily. b. maintain their child's room as the child left it 2 years ago. c. keep a place set for the dead child at the family dinner table. d. throw flowers on the lake at each anniversary date of the accident.

d. throw flowers on the lake at each anniversary date of the accident.

88. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? a."Have you been a victim of a crime or seen someone badly injured or killed?" b."Do you feel especially uncomfortable in social situations involving people?" c."Do you repeatedly do certain things over and over again?" d."Do you find it difficult to control your worrying?"

d."Do you find it difficult to control your worrying?"

8. A patient diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" Select the nurse's best response. a."Nothing you are saying is clear." b."Your thoughts are very disconnected." c."Try to organize your thoughts and then tell me again." d."I am having difficulty understanding what you are saying."

d."I am having difficulty understanding what you are saying."

CHAPTER 14 51. A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a."Things will look brighter soon. Everyone feels down once in a while." b."Our staff members care about you and want to try to help you get better." c."It is difficult for others to care about you when you repeatedly say the same negative things." d."I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

d."I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

31. A patient diagnosed with schizophrenia and auditory hallucinations anxiously tells the nurse, "The voice is telling me to do things." Select the nurse's priority assessment question. a."How long has the voice been directing your behavior?" b."Does what the voice tell you to do frighten you?" c."Do you recognize the voice speaking to you?' d."What is the voice telling you to do?"

d."What is the voice telling you to do?"

20. A nurse sits with a patient diagnosed with schizophrenia. The patient starts to laugh uncontrollably, although the nurse has not said anything funny. Select the nurse's best response. a."Why are you laughing?" b."Please share the joke with me." c."I don't think I said anything funny." d."You're laughing. Tell me what's happening."

d."You're laughing. Tell me what's happening."

7. A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?a.Clozapine(Clozaril) b.Ziprasidone (Geodon) c.Olanzapine (Zyprexa) d.Aripiprazole (Abilify)

d.Aripiprazole (Abilify)

25. A patient diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident?a.Neologism c.Thought broadcasting b.Idea of reference d.Associative looseness

d.Associative looseness

85. A patient undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?a.Displacement c.Projection b.Regression d.Denial

d.Denial

76. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a.Arms crossed c.Smiling inappropriately b.Staring at the nurse d.Eyes pointed downward

d.Eyes pointed downward

32. A patient receiving risperidone (Risperdal) reports severe muscle stiffness at 1030. By 1200, the patient has difficulty swallowing and is drooling. By 1600, vital signs are 102.8° F; pulse 110; respirations 26; 150/90. The patient is diaphoretic. Select the nurse's best analysis and action. a.Agranulocytosis; institute reverse isolation. b.Tardive dyskinesia; withhold the next dose of medication. c.Cholestatic jaundice; begin a high-protein, high-cholesterol diet. d.Neuroleptic malignant syndrome; notify health care provider stat.

d.Neuroleptic malignant syndrome; notify health care provider stat.

23. A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a.Poverty of content c.Neologisms b.Concrete thinking d.Paranoia

d.Paranoia

59. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a.Dry mouth c.Nasal congestion b.Blurred vision d.Urinary retention

d.Urinary retention

14. Withdrawn patients diagnosed with schizophrenia: a.are usually violent toward caregivers. b.universally fear sexual involvement with therapists. c.exhibit a high degree of hostility as evidenced by rejecting behavior. d.avoid relationships because they become anxious with emotional closeness.

d.avoid relationships because they become anxious with emotional closeness.

84. A patient checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states this event is not likely. This counseling demonstrates principles of: a.flooding. c.relaxation technique. b.desensitization. d.cognitive restructuring.

d.cognitive restructuring.

65. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a.monitors sodium intake and weight daily. b.wears support stockings and elevates the legs when sitting. c.can identify foods with high selenium content that should be avoided. d.confers with a pharmacist when selecting over-the-counter medications.

d.confers with a pharmacist when selecting over-the-counter medications.

34. The nurse is developing a plan for psychoeducational sessions for several adults diagnosed with schizophrenia. Which goal is best for this group? Members will: a.gain insight into unconscious factors that contribute to their illness. b.explore situations that trigger hostility and anger. c.learn to manage delusional thinking. d.demonstrate improved social skills.

d.demonstrate improved social skills.

74. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a.bring up the issue at the community meeting. b.calmly tell the patient, "You must bathe daily." c.avoid forcing the issue in order to minimize stress. d.firmly and neutrally assist the patient with showering.

d.firmly and neutrally assist the patient with showering.

61. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a.guilt and despair. c.interest and pleasure. b.over-involvement. d.ineffectiveness and frustration.

d.ineffectiveness and frustration.

30. A patient diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror." While listening, the nurse should: a.sit close to the patient. b.place an arm protectively around the patient's shoulders. c.place a hand on the patient's arm and exert light pressure. d.maintain a normal social interaction distance from the patient.

d.maintain a normal social interaction distance from the patient.

28. A patient diagnosed with schizophrenia has been stable for a year; however, the family now reports the patient is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The patient says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of: a.the need for psychoeducation. c.chronic deterioration. b.medication noncompliance. d.relapse.

d.relapse.